A new resolution for global mental health

The right to work and employment is indispensable for social integration of persons with mental health problems. This study examined whether existing laws pose structural barriers in the realization of right to work and employment of persons with mental health problems across the world. It reviewed disability-specific, human rights legislation, and labour laws of all UN Member States in the context of Article 27 of the UN Convention on the Rights of Persons with Disabilities (CRPD). It wes found that laws in 62% of countries explicitly mention mental disability/impairment/illness in the definition of disability. In 64% of countries, laws prohibit discrimination against persons with mental health during recruitment; in one-third of countries laws prohibit discontinuation of employment. More than half (56%) the countries have laws in place which offer access to reasonable accommodation in the workplace. In 59% of countries laws promote employment of persons with mental health problems through different affirmative actions. Nearly 50 years after the adoption of the International Covenant on Economic, Social, and Cultural Rights and 10 years after the adoption of CRPD by the UN General Assembly, legal discrimination against persons with mental health problems continues to exist globally. Countries and policy-makers need to implement legislative measures to ensure non-discrimination of persons with mental health problems during employment.

Doctors criticise UN's approach to global drugs control

INTRODUCTION On August 8, 2016, the Mental Health Care (MHC) Bill, 2016 was passed in the Rajya Sabha. If the Bill is passed in the Lok Sabha, then it repeals the Mental Health Act, 1987. The Government of India ratified the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) in 2007.[1] The Convention requires the laws of the country to align with the Convention. The new Bill was introduced as the existing Mental Health Act, 1987 does not fulfill the obligations of the UNCRPD.[2] The preamble of the MHC Bill, 2016 clearly depicts that this legislation is to protect, promote, and fulfill the rights of such persons during delivery of MHC and services.[3] The Bill is progressive and rights based in nature. The whole dedicated Chapter (v) on "Rights of the persons with mental illness" is the heart and soul of this legislation. However, the Bill mainly focuses on the rights of the persons with mental illness only during treatment in hospital and it is completely silent about the care of the persons with mental illness in community.[3] MHC priorities need to be shifted from psychotic disorders to common mental disorders and from mental hospitals to primary health centers. Increase in invisible mental problems such as suicidal attempts, aggression and violence, widespread use of substances, and increasing marital discord and divorce rates emphasizes the need to prioritize and make a paradigm shift in the strategies to promote and provide appropriate mental health services in the community.[4] There are several significant positive developments in the new Bill. First, there is a mention of decriminalization of attempted suicide. It is specifically stated that there is a presumption of severe stress in person with attempted suicide and such person shall not be tried and punished under the said code. Moreover, it is highlighted that the appropriate Government will be bound not only to provide care, treatment, and rehabilitation of such persons but also to take measures to reduce its recurrence. This is an important and progressive step which will have positive implication throughout the country.[5] Second, there is a detailed description on "Rights of person with mental illness." This is highly significant step to make the Bill as patient-centric. There is a mention of the right to access MHC and treatment at affordable cost, good quality which is acceptable to person with mental illness, their family members, and caregivers. The onus will be on appropriate Government to make such provisions for range of services including outpatient and inpatient services, half-way homes, sheltered accommodation, supported accommodation, hospital- and community-based rehabilitation, free cost of medicines, specialized services of child and adolescent, and old age mental health. The appropriate Government will ensure necessary budgetary provisions for effective implementation along with integration of mental health services into general health care at all levels of health. Every person with mental health illness will have right to protection from cruel, inhuman, and degrading treatment. Third, the key feature in this new Bill is the provision for medical insurance for treatment of mental illness at par with physical illness by all insurers. Mental health insurance has remained a neglected area for long. This new feature will have huge and significant impact for the persons with mental illness, family, and caregivers.[6] Fourth, the new Bill clearly describes the "Duties of appropriate Government." This is a unique feature as the appropriate Government will have responsibility to plan, design, and implement programs for mental health such activities related to promotion, prevention, reduction of suicide, stigma. The important aspect will also to address the human resource needs which include training of medical officers and other persons. There are many other favorable aspects of this new Bill, which are beyond the scope of description here. In general, there are several features which may be seen as welcome step by persons with mental illness, their family, caregivers, professionals, care providers, and significant others. However, it seems ambitious and poses a huge responsibility and challenge to all stakeholders for its effective implementation. The new Bill tries to be overinclusive in its approach stretching beyond its legislative limit, and despite noble intentions behind it, it would be a challenge for the stakeholders whether the contents of the Bill are legislation, program, policy, or even a treatment guideline. There are highly qualified and accountable bodies to design a program or to recommend the treatment guidelines. There is a need to draw a distinction between the act and the rules, while the former is stable and constant over the years and latter are subject to change. The major task would be to effectively formulate the Rules which take into the account the opinions of all stakeholders and in the best interest of the person with mental illness. On a closer look, this Bill premises on a hypothesis that the MHC providers and family members are the main violators of the rights of the persons with mental illness, which is unfortunate. On the other hand, the Bill does not take into account of family members' significant contribution, caregivers' burden, isolation, frustration, and violence they undergo because of persons with mental illness.[7] The Bill is silent on the role and contribution of family members in providing care. Unlike the West, in India, family is the key resource in the care of patients with mental illness.[7] Families assume the role of primary caregivers for two reasons. First, it is because of the Indian tradition of interdependence and concern for near and dear ones in adversities. Second, there is a paucity of trained mental health professionals required to cater to the vast majority of the population;[8] hence, the clinicians depend on the family. Thus, having an adequate family support is the need of the patient, clinician, and the healthcare administrators.[7] Unfortunately, that Bill does not foster the need to support the family members in providing care. The Mental Health Act, 1987 legislation focused on admission and treatment of persons with severe mental illness in mental hospitals[9] when they were detained against their will.[1] However, the MHC Bill, 2016 tries to regulate almost all the MHC establishments. This could be avoided by legislation focusing on MHC institutes, where patients are admitted against their will for treatment. The Mental Health Act, 1987 was not implemented across the country because of severe shortage of resources;[9] however, a new MHC Bill, 2016 has been introduced without addressing the issues which haunted the Mental Health Act, 1987.[10] Although there are many positive aspects of the MHC Bill, 2016, the negative aspects have severe and negative impact of the MHC in India. This article focuses on the shortcomings of the MHC Bill, 2016. MENTAL HEALTH CARE BILL, 2016: CHALLENGES AND REMEDIES Definition of mental health establishment National Mental Health Programme (NMHP) (National policy) advocates integration of mental health into general and primary health care.[11] However, the Bill mandates all the establishments to take license for treating patients; this may come in the way of integrating mental health into general health and, thus, the implementation of the policy. Many private hospitals and nursing homes may refuse to treat patients with mental illness reporting that they do not have license to do so. Hence, the proposed Bill should be in line with the NMHP (Mental health policy). To encourage treatment in general hospitals, they need to keep those establishments out of the purview of licensing.[1] The proposed Bill enthusiastically moves forward (without acknowledging the available meager resources) to protect and promote human rights of persons with mental illness by mandating licensing of the mental health establishments. There are many hostels, prisons, jails, juvenile home, child protection centers, reception centers, centers for destitute, beggars' home, religious places such as temples, churches, and dargahs, and faith healers need to take license to keep persons with mental illness. This will defeat the purpose of the Bill and will invite "license raj" of harassing the MHC providers. It would be prudent to keep the general hospital psychiatry units and nontreatment providing centers to be kept out of the purview of licensing.[1] Capacity to make mental health care and treatment decisions This issue of capacity to make MHC and treatment decisions is inadequate and may have dangerous consequences because person with mental illness may refuse treatment due to (a) absent insight, (b) severe mood symptoms, and (c) his/her symptoms are coming in the way of decision-making. Family members usually find it difficult to manage individuals with serious mental illnesses, who have no insight, and usually, they refuse admission and treatment. This clause by default considers that everyone has capacity and one has to prove that person with mental illness lacks capacity before initiating involuntary treatment. One has to approach the mental health board to take permission to initiate involuntary treatment. There is no scope to take guardians' consent to initiate involuntary treatment under the new Bill. This will add an enormous burden to family members and MHC providers in treating involuntary patients with severe mental disorders.[12] This clause is either to be deleted or to be considered informed consent from the parents and family members, or two doctors (preferably one of them is a psychiatrist) opinion is taken to initiate involuntary treatment. This can help the patient and also the family members in providing timely care. The Supreme Court of Canada has dealt similar issue in a well-known celebrity case referred as "Canada's Beautiful Mind" that a law that allows a person with a mental illness to be incarcerated indefinitely in a "hospital" because needed psychiatric treatment cannot, by law, be provided is not justifiable in a caring democratic jurisdiction.[13] Hence, the new Bill needs to make provision for treatment (involuntary) in all supported (involuntary) admissions through informed consent from the parents and/or by family members to restore liberty by treatment. It has been stated very rightly that in the regulation of involuntary treatment, a balance must be found between duties of care and protection and the right to self-determination.[14] Advance directives Person with mental illness may revoke, amend, or cancel advanced directives many times in a day, and family members will be finding difficult to handle such situations. Only the mental health board has powers to amend or overrule the advance directive. This needs to be done in very short time to enable the treatment (24–48 h). If patient has written costly treatment or private/corporate hospital (which family cannot afford) in advance directives, then who will bear the cost of costly treatment. Considering the available human resources (Medical and Judicial), economic constraint, and our collective community efforts in treating patients with mental illness, our Indian population is not ready for such advanced directives. Above all these, research studies data do not support the use of advance directives in person with mental illness (Cochrane review). It would be prudent to do more research in this area in our population before to introduce this advance directive.[15] This advance directive operates on the basic premise that "if a person develops mental illness" Which mental illness? If multiple illnesses occur? If it becomes comorbid with physical illness? What severity? Under what circumstances? Above issues are wide open and threaten each individual. If an MHC provider writes an advance directive, he/she need to write for each disorder "if I develop mania," "If I develop schizophrenia," like a textbook, how he/she should be care or not to be cared. This advance directive will welcome more litigations and heavy burden on family members. It is advisable that advance directive needs to be kept out of the purview of the Bill.[16] The Cochrane database of systematic review on advance treatment directives for people with severe mental illness reported that there are too few data available to make definitive recommendations to introduce it.[17] Even in the West, this has certainly not had its intended benefit. For the Indian reality, to be rushing in with legislation on this count is rather hasty and ill conceived.[1418] Nominated representative A person with mental illness may revoke his/her decision of nomination of a representative as he/she suffers by reason of severe mental illness coloring his/her perception, alter many times in a day too. (1) Only mental health board has powers to overrule the nominated representative. (2) This needs to be done in very short time to enable the treatment. (3) If nominated representative is requesting for costly treatment (which family cannot afford), then who will bear the cost of costly treatment: is it family? or nominated representative? or the State? (4) Considering the available human resources (Medical and Judicial), economic constraint, and our collective community efforts in treating patients with mental illness, our Indian population is not ready for such a departure from family as a caregiver to a patient chosen nominated representative. (5) This nominated representative breaks the Indian family system who cares and bears the brunt of patents unpleasant behavior and still willing to support his/her treatment.[7] Ultimately, family may disown the patient and which may have serious consequences in the form of abandoning the patient and wandering mentally ill at large, which defeats the very purpose of the Bill in protecting the patient. Family members are the true value and assets in the Indian context to provide community care for persons with mental illness. Hence, family members are the natural guardians until proven otherwise. This "Nominated Representative" breaks the very backbone and fabric of our society "the family." In all most, all the cases, family members are the caregivers this needs to be fostered and enhanced. This clause on Nominated Representative needs to be removed from the Bill.[16] Mental health review boards The district-level mental health review boards, which are quasi-judicial bodies overseeing the effective implementation of the MHC delivery system, could introduce new hurdles for treatment delivery and unnecessary delay. This could be simply because of nonavailability of judicial workforce and other resources to operate at every district levels. If these issues are not addressed, this may cause delay in initiating treatment, which may cause enormous amount of stress on the care providers. Delay in addressing the issue can defeat the purpose of the Bill. If these boards do not operate on day-to-day basis at each hospital level, then this can cause serious adversarial impact on the MHC of the person. Unfortunately, MHC is taking an ugly turn similar to western country where involuntary MHC is argued in the court of law. MHC is becoming a tedious, prolonged, and costly judicial proceeding. These mental health review boards need to have time limit (<72 h) to take decision, especially with regard to capacity to consent for treatment issues. The mainstream judicial system is incapable of handling such complaints because of lack of sensitivity and also being clogged with a huge pendendency of mainstream cases.[12] These boards need to move away from tardy judicial process/procedures. Alternatively, the first level of review could be independent hospital review board, which can address those contentious issues in a cost-effective and timely manner at the patient's doorsteps/hospital. Hence, it would be prudent to create consumer-friendly (independent) MHC hospital boards at every hospital using local resources. This MHC hospital board could be comprised of independent psychiatrist/mental health professionals, family caregivers, and recovered patient. Another alternative is to create a board of visitors at each hospital (along the lines of Mental Health Act, 1987) to perform similar functioning. Right to confidentiality The Bill also gives power to nominated representative to unlimited access to the records of the persons with mental illness. Mental health professionals have expressed reservations over sharing of information, describing it as "breach of confidentiality," as per the Medical Council Ethics, 2002.[19] However, according to the Bill, information regarding MHC needs to be shared with the nominated representative. This issue impinges on the fundamental rights – "right to privacy." Hence, there is a need to introduce a clause that information shared will be only with family members and will be in verbal form only. Written documents or medical records will be shared only with patients/legal authorities on obtaining a written request. Punishment for contravention of any of the provisions of the Bill/rule Punishments are too harsh and there is no provision for whether contravention is accidental or due to practical difficulties or deliberate. Medical personnel is already covered under various legislations such as Consumer Protection Act, MCI, and civil and criminal laws for any medical negligence. There are various other commissions such as Human Rights Commission, Women Commission, and Child Welfare Committee to protect the rights of the persons with mental illness. Unlike the other patients, behavior and responses of mentally ill are different, especially in patients with paranoid delusions. Such people are likely to complain against hospital/doctors or other personnel which he may feel true because of his/her illness but are not true. This litigation-based MHC can give rise to a defensive practice, and tendency to avoid care of such patients will only harm such patients and their family members. This will also increase the cost of MHC. There should be a provision for an independent expert committee/mental health board at hospital levels to review such complaints, and only complaints which have prima facie found to be true should be referred to the District Mental Health Board. Otherwise, there will be innumerable complaints making the hospital authorities/doctors and other personnel spend more time in the District Boards than in hospital treating patients. Discharge planning The psychiatrist is expected to be responsible for patient care and treatment in the future after discharge. This clause is idealistic but may not be possible in custodial care (involuntary patients), destitute patients, and voluntary admissions, wherein only the patient can be briefed or counseled regarding the future treatment. The ultimate decision of continuing treatment or not is the choice of the patient. Discharge planning should not be considered as negligence as it is not possible without active cooperation of the patient and family members. If the law makers are very serious about this issue of "the continuity of care," then they should enable the MHC providers and family members by introducing the Compulsory Community Treatment Order. Unfortunately, the Bill is silent on the much-needed community treatment order. Inclusion of compulsory community treatment orders may play a significant role in providing care for the chronically ill patients and also better the lives of the family members and caregivers. Availability of community treatment order to the family members and caregivers enables them to provide continuous care. The community treatment order brings relief to families of person with mental illness, encourages use of less restrictive forms of inpatient treatment, violence, unnecessary and brings to the lives of the mentally Hence, there is a need to have a community treatment order in The Compulsory community treatment order is and can be with our society and resources. of such law can in continuity of care after discharge. for research The Bill mandates Mental Health to permission for many and can or research in persons with mental illness. There is a need to this clause to permission for and to with per the of family members during admission and treatment The Bill the role of family members in providing care in hospital The Bill needs to make provisions that at one family needs to be with the patient during inpatient treatment. There is a need that family members need to be in the provision of the care. This not only patient's rights but also family members in active treatment such as and family to be and also in rehabilitation which huge in continuity and of the treatment.[7] If there are no family members, the medical board two mental health will of the of family Hence, there should be on such admissions along with their or to encourage family support during which physical support to the person with mental illness.[7] family members will the mental hospital to the of and Many such as and many other centers for across India have the of family during inpatient care. A clause needs to be introduced involuntary inpatient treatment is by default one family needs to and be with the persons with mental illness during inpatient treatment. The for inpatient for supported admission needs not when family members are in the and in treatment and A for admission with family members needs to be introduced and family support system to provide to the that have been beyond in Indian research across the of of persons with severe mental illness is completely and integration of mentally ill into the community and of their assets and are completely There is a need to have this issue of of of persons with severe mental illness to be in the proposed Bill. The treatment and need to be as per the guidelines. The board needs to take the bodies opinion in case of in treatment and is a form of treatment for patients with of suicidal and and patients. In treatment, is a form of treatment and in has been in the Bill. If this clause is not effective treatment will be to the patient can be is usually in ill patients. for the for in or is the much-needed treatment. psychiatrist needs to have the right to about treatment with the consent of family members. The Bill should not or on acceptable of resources The Bill is highly with the which is similar to the western society resources are in many than India. The issue in our society with regard to the of implementation of the MHC Bill is the of There have been serious about the of resources such as workforce and and also will for implementation of the Bill. The major is lack of especially in the and There are problems such as inadequate mental health for and of the available mental health resources to general health In lack of regarding mental health the and to the If mental health services are not available in the district where the patient then that such person is to access any other mental health in the district and the of treatment at such establishments in that district will be by the appropriate This based mental health issues can to and many of them of the existing meager resources. of the the Bill needs to and make provisions and a through and detailed in the Bill for mental health workforce on similar lines of Mental Health of in the The Bill needs to introduce for of workforce a time There is also an need to introduce at the level that every should to treat mental This responsibility needs to be to a for and the of workforce The need of the is in addressing major such as lack of mental health and which are the major to psychiatric services in the community.[4] of The Bill is silent and does not the to for of or district the workforce resource for the Bill is highly in the and also in the area of mental health treatment. Hence, training of workforce needs to be considered to the existing The Bill should provision of adequate resources for of these There has been a major shift from or custodial care as in the Indian Act, when the effective treatment was to the Mental Health of 1987 that mainly focused on the treatment and care of mentally ill with efforts to reduce and cater for their human to the MHC Bill of 2016 that focuses mainly on the human rights of persons with mental illness and their the care of the persons with mental illness. the Bill, there an of the and of mental ill patients along with that the It is prudent for the to account for the of the developments in the mental health the needs of the patients and family, make provisions to the treatment make provisions to the workforce resources and health in the of mental provide services, promote such patients, and make provisions for adequate and while making law of the The need of the is a law that can be implemented in that can cater to the health needs at all levels of and levels of while protecting the human rights of the mental health as as the and their support and of interest There are no of

About 3 by 5: Since its introduction in 1996, highly active antiretroviral therapy (ART) has enabled people with HIV/AIDS in industrialized countries to live healthier, longer lives and to continue to contribute to the social and economic well-being of their families and societies. However, although 95% of the world's 40 million HIV-positive people are living in developing countries, only about 400 000 of the six million people requiring treatment actually received it in 2003. To address this treatment gap, at the UN General Assembly Special Session on HIV/AIDS in 2001, UN Member States unanimously committed to scaling up ART within their national HIV/ AIDS programmes. In late 2003, and UNAIDS declared the inequity in access to HIV/AIDS treatment a global public health emergency and launched the initiative, dubbed 3 by 5, which aims to treat three million people living with HIV in developing countries by the end of 2005. In a special interview with the Bulletin, WHO's Director of HIV/ AIDS explains the principles behind the strategy, describes the challenges to its success and recounts the progress made towards achieving the target to date. Bulletin: Why has chosen HIV/ AIDS for the signature initiative of the current Director-Generalship? JK: There are many reasons. One of the reasons is that for certain areas of the world the threat of HIV/AIDS is more severe than almost any other disease that we've seen for many hundreds of years. This is not to say that other diseases are not important but HIV/AIDS is clearly the disease that could define our generation. It is killing a particular portion of the population which is the most important for social viability: young men and women in the prime of their fives, people who are key to a community's social and economic structure. It is an enormously serious problem, as the World Bank points out, when a country loses people in whom so much has already been invested and who must in turn invest in the next generation, if societies are to be sustained. By choosing to focus on the HIV/ AIDS treatment gap, WHO's Director-General, Dr LEE Jong-wook, recognized that has an important role to play in combating this epidemic. This is because scaling-up treatment for HIV in developing countries requires a public health approach. Until now, the only way H[V could be treated was in a very clinical, hospital-based, first-world type approach, where physicians were the only ones who could treat HIV patients. In order to quickly and equitably roll out HIV treatment in resource-poor settings, we could not take a one doctor, one patient approach. We had to develop ways of treating many thousands of people within a population using standardized regimens and simple treatment algorithms. WHO has been saying for years that we need to invest more in health and in some ways, we have been successful--the world is investing more in health but almost all of the new investment is for HIV. The world has voted--presidents and prime ministers have voted--to put their, money into the fight against HIV/AIDS. For to turn its back on HIV/AIDS would therefore be tantamount to a dereliction of duty. It's an opportunity we cannot afford to miss. must therefore help the world achieve its goals but at the same time make sure that those goals contribute to broader social development. Bulletin: Is there more to 3 by 5 than treatment? JK: Yes. In providing HIV treatment, we can achieve many other things at the same time. For example, by increasing access to ART, we have learnt that we can reduce the stigma associated with HIV infection. In the first world, the availability of ART--which can dramatically transform dying people back into healthy, productive individuals--was a critical factor in reducing the stigma associated with HIV and in enabling people to resume their lives. Secondly, providing HIV treatment also strengthens prevention. …

Meeting the UN Sustainable Development Goals for mental health: why greater prioritization and adequately tracking progress are critical.

Opportunities in mental health services research.

The World Health Organization (WHO) is revising the ICD-10 classification of mental and behavioural disorders, under the leadership of the Department of Mental Health and Substance Abuse and within the framework of the overall revision framework as directed by the World Health Assembly. This article describes WHO's perspective and priorities for mental and behavioural disorders classification in ICD-11, based on the recommendations of the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. The WHO considers that the classification should be developed in consultation with stakeholders, which include WHO member countries, multidisciplinary health professionals, and users of mental health services and their families. Attention to the cultural framework must be a key element in defining future classification concepts. Uses of the ICD that must be considered include clinical applications, research, teaching and training, health statistics, and public health. The Advisory Group has determined that the current revision represents a particular opportunity to improve the classification's clinical utility, particularly in global primary care settings where there is the greatest opportunity to identify people who need mental health treatment. Based on WHO's mission and constitution, the usefulness of the classification in helping WHO member countries, particularly low- and middle-income countries, to reduce the disease burden associated with mental disorders is among the highest priorities for the revision. This article describes the foundation provided by the recommendations of the Advisory Group for the current phase of work.

The outcome document from the UN General Assembly Special Session (UNGASS) represents political commitments and serves as a framework to guide national and international work. In this editorial the author argued that to deal effectively with HIV/AIDS there is a need to recognize the limitations of the special session. UNGASS’s over time stems from the fact that it can form the justification for resource allocation and priority setting and that it sets out specific targets for achievement on which governments are expected to report publicly. Although it recognizes the rhetorical value of human rights it makes the issue a separate component of the response rather than fully integrated within it. It is noted that the policy and strategic documents of the UN system to address HIV/AIDS that predate the UNGASS are also far more inclusive of many of the issues that the declaration does not address. However the UNGASS declaration is far reaching in its recognition that access to medications in the context of HIV/AIDS is a fundamental element of the right of all people. Thus in the context of the Declaration countries are held more accountable in their actions in preventing and providing treatment to HIV infected people.

This paper summarizes the findings for the European Region of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. The article presents a description of the region, an overview of mental health policies and legislation, a summary of relevant research in the region, a precis of community mental health services, a discussion of the key lessons learned, and some recommendations for the future.

Alex Coutinho: transforming HIV care in Africa

PurposeThe purpose of this paper is to show a reflection of one year on how the UN General Assembly Special Session (UNGASS) event was unfolded and its impacts and longer term implications.Design/methodology/approachThis paper is a consideration of relevant past and present documentation and commentary. Experiences as a participant at some of the events described.FindingsUNGASS was called for by countries affected by the failings of the existing conventions who wanted to introduce reformed alternative policies. Representatives of the status quo who opposed such change were partially successful in retaining some aspects of the prohibition approach and in minimising dissent and debate.Research limitations/implicationsSome decision-making discussions were not open to all potential participants – governmental, regional and civil society, including the author.Practical implicationsThe wider debate prompted by the UNGASS indicated a breakdown in the previous consensus around the prohibition and punitive paradigm of the international conventions.Social implicationsGreater emphases on health and human rights aspects of international drug policy were included in the final documents. This provides scope for continued evolution of these emphases in the future.Originality/valueThe paper presents an account of the UNGASS and pre-UNGASS proceedings from the point of view of a reform-minded participant.

BackgroundAlthough attention to human rights in Indonesia has been improving over the past decade, the human rights situation of persons with mental disorders is still far from satisfactory. The purpose of this paper is to examine the legal framework for protection of human rights of persons with mental disorder and the extent to which Indonesia's international obligations concerning the right to health are being met.MethodsWe examined the Indonesian constitution, Indonesian laws relevant to the right to health, the structure and operation of the National Human Rights Commission, and what is known about violations of the human rights of persons with mental illness from research and the media.ResultsThe focus of the Indonesian Constitution on rights pre-dated the Universal Declaration, Indonesia has ratified relevant international covenants and domestic law provides an adequate legal framework for human rights protections. However, human rights abuses persist, are widespread, and go essentially unremarked and unchallenged. The National Human Rights Commission has only recently become engaged in the issue of protection of the rights of persons with mental illness.ConclusionMore than legislation is needed to protect the human rights of persons with mental illness. Improving the human rights situation for persons with mental illness in Indonesia will require action by governments at national, provincial and district levels, substantial increases in the level of investment in mental health services, coordinated action by mental health professionals and consumer and carer organisations, and a central role for the National Human Rights Commission in protecting the rights of persons with mental illness.

BackgroundRecognising the substantial political weight of the United Nations General Assembly (UNGA), a UN General Assembly special session (UNGASS) and high-level meetings (HLMs) have been pursued and held for 5 health-related topics thus far. They have focused on human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS, 2001), non-communicable diseases (NCDs, 2011), antimicrobial resistance (AMR, 2016), tuberculosis (TB, 2018), and universal health coverage (UHC, 2019). This observational study presents a comprehensive analysis of the political and policy background that prompted the events, as well as an assessment of aims, approaches, and ultimate outcomes.Methods and findingsWe investigated relevant agencies’ official documents, performed a literature search, and accessed international institutions’ websites for the period 1990–2020. Knowledgeable diplomatic staff and experts provided additional information. Outcomes were evaluated from a United Nations perspective based on national and international commitments, and funding trends. Eliciting an effective governmental response through UNGASSs/HLMs is a challenge. However, increased international commitment was evident after the HIV/AIDS (2001), NCDs (2011), and AMR (2016) meetings. The more recent TB (2018) and UHC (2019) HLMs have received general endorsements internationally, although concrete commitments are not yet documented. Although attribution can only be hypothesized, financial investments for HIV/AIDS following the UNGASS were remarkable, whereas following HLMs for NCDs, AMR, and TB, the financial investments remained insufficient to face the burden of these threats. Thus far, the HIV/AIDS UNGASS was the only one followed by a level of commitment that has likely contributed to the reversal of the previous burden trend. Limitations of this study include its global perspective and aerial view that cannot discern the effects at the country level. Additionally, possible peculiarities that modified the response to the meetings were not looked at in detail. Finally, we assessed a small sample of events; thus, the list of strategic characteristics for success is not exhaustive.ConclusionsOverall, UNGASSs and HLMs have the potential to lay better foundations and boldly address key health challenges. However, to succeed, they need to (i) be backed by large consensus; (ii) engage UN authorities and high-level bodies; (iii) emphasise implications for international security and the world economy; (iv) be supported by the civil society, activists, and champions; and (v) produce a political declaration containing specific, measurable, achievable, relevant, and time-bound (SMART) targets. Therefore, to ensure impact on health challenges, in addition to working with the World Health Assembly and health ministries, engaging the higher political level represented by the UNGA and heads of state and government is critical.

Reforming international drug policy

Palliative Care and Human Rights: A Decade of Evolution in Standards