Five-year plans and once-in-a-decade interventions: Need to move from filling gaps to bridging chasms in mental health care in India.

Abstract

Byline: Pratima. Murthy, Mohan. Isaac Introduction In a country of 1.33 billion people spread across 29 states and 7 union territories (UTs), 630 districts (with more than 23,000 primary health-care centers - the primary unit for health care), 22 official languages and over a 1000 dialects, a population that is 70% rurally located, nearly 25% illiterate, and about one in five below the poverty line, the challenges faced in the delivery of mental health care can be extremely complex. Added to this complexity, there is yet another often cited reason – that as per the Constitution of India, health is a state subject and not under the control of the central government.[sup][1] There are three broad themes that illustrate the landscape of mental health services in India in contemporary times. First is the theme of judicial activism driving the development of mental health services in the country. The second is the governmental response. The third and overwhelming theme is one of polemics-public or private, community or specialized care, health or social welfare, stand-alone mental health services or integrated services, and finally perhaps, most importantly, center or state. Public Interest Litigation and Judicial Intervention The most notable initiatives that have to some extent shaken off the inertia in mental health-care reform are the public interest litigations (PILs) and the judicial responses that occurred over the last three decades.[sup][2] The first such in the 1980s (Upendra Baxi vs. State of UP and others) concerned the “inhuman treatment of inmates” of a protection home in Agra and argued for their “right to live a life of dignity” as enshrined in Article 21 of the Constitution of India. A number of PILs subsequently followed the issues that were raised included concerns about mentally ill prisoners languishing in jails (Veena Sethi vs. State of Bihar 1982), the state of the public Shahdara Mental Hospital in New Delhi (BR Kapoor and others vs. Union of India 1983 and PUCL and others vs. Union of India and others 1983), the detention of abandoned children and those with mental retardation “in jails for safe custody” (Sheila Barse and others vs. Union of India and Ors 1986). In response, the Supreme Court ordered the monitoring of such homes, directed the National Human Rights Commission (NHRC) to monitor specific mental hospitals, and declared keeping of mentally ill in jails as illegal and unconstitutional, leading to the release of many “noncriminal lunatics” from jails. Another resulting development was the formation of the Institute of Human and Behaviour and Allied Sciences, where the Shahdara Mental Hospital was earlier. The philosophy of care in mental health institutions was perhaps best illustrated in the case of Chandan Kumar Bhanik versus the state of West Bengal in 1988 where the apex court observed: “Management of an institution like the mental hospital requires flow of human love and affection, understanding and consideration for mentally ill persons. These aspects are far more important than a routinized, stereotyped, and bureaucratic approach to mental health issues.”[sup][2],[3] Mental Hospital Monitoring As part of the mandate of the Supreme Court in 1997, the NHRC began monitoring the functioning of the mental hospitals at Agra, Gwalior, and Ranchi. The NHRC “used monitoring as a tool of correction and promotion of human rights of persons with mental illness”.[sup][3] In addition to monitoring the functions of the three assigned hospitals, the NHRC also supported an initiative on quality assurance in mental health. This evaluation, undertaken by the National Institute of Mental Health and Neurosciences (NIMHANS) in 1998, included an evaluation of the mental hospitals in the country through questionnaires and personal visits, as well as a review of the existing general hospital psychiatry units and private psychiatric institutions. …