Various commentaries have appeared in mainstream media hailing the passage of the Mental Health Care Bill (MHC) in the Rajya Sabha during its last session. Given the general lack of awareness on issues concerning mental health and psychosocial disabilities, this is welcome.
Many of these commentaries, however, were confined to just one aspect of the Bill ie, decriminalisation of suicide, an issue that has been in debate for quite some time. However, there are various other aspects of the Bill, some of which we shall try to look into here.

A Paradigm shift
The passage of the Bill, which replaces the Mental Health Act, 1987 marks the culmination of a six-year long process, which began in 2010 when the draft of a Mental Health Care Bill was placed in public domain for comments.
Though some activists are critical of the Bill for not meeting all concerns and term it as a “work in progress”, the Bill marks a paradigm shift from viewing persons with psychosocial disabilities requiring institutionalisation, to persons enjoying equal rights, legal capacity and autonomy. This change in perception has also to be looked at in the background of India signing and ratifying the United Nations Convention on Rights of Persons with Disabilities (UNCRPD). Having ratified the UNCPRD India is bound to harmonise its domestic laws in accordance with the provisions of the UNCRPD which inter alia recognise the legal capacity of persons with psychosocial disabilities.
The most significant aspect of the Bill is that for the first time the Right to health care, albeit mental health is being enshrined. The onus for making this right real rests solely with the government. The Bill is pathbreaking in as far it lays down clear responsibilities of the State and expands access to treatment. Given the dismally poor state in which it is today, this should, if properly implemented, bring about a qualitative change.

The Bill lays down that “appropriate Government shall have the duty to plan, design and implement programmes for the promotion of mental health and prevention of mental illness in the country.” Apart from providing everyone the right to access mental health care as well as treatment from mental health services, run or funded by the government, the Bill also entrusts the government with the responsibility of providing supply of all notified essential drugs free of cost to those with mental illness. Given the fact that many families are unable to access treatment due to the prohibitive costs of drugs, this is a major gain.
A comparison with the predecessors of the current Bill -- the Indian Lunacy Act, 1912 and the Mental Health Act, 1987 – would be worth making while analysing the current Bill.
The primary focus of the Indian Lunacy Act was protecting society from persons with mental illness. The emphasis on custodial care in institutions should be seen in this context. It was assumed that persons with mental illness will have to live in such custodial institutions or asylums. Therefore rules had to be framed for admission to such institutions among other things.
As compared to the Lunacy Act, the Mental Health Act, which replaced it, can be considered progressive. As opposed to custodial care, it contained provisions for treatment of persons with mental illness in general hospitals as well as provisions for discharge of those detained in institutions. However, with respect to guardianship and management of property of persons with psychosocial disabilities, the same provisions as existed in the Lunacy Act continued. Mental health activists were also critical of the fact that the Act was more concerned with the regulation and administration of mental health care within institutions and failed to address mental health issues as also protecting the rights of persons with psychosocial disabilities.

Status of mental health today
Despite its severity, the country had to wait till 2014 for a national mental health policy. The policy did talk about according priority to reducing the treatment gap by providing universal access to mental health care. It also acknowledges the paucity of mental health services as also the stigma, marginalisation, abandonment and discrimination that people with psychosocial disabilities face.
Mental health treatment in India has mostly been confined to large asylums and hospitals, conditions of which are deplorable and inhospitable. It is estimated that around 80 percent of beds are located in such institutions. Furthermore, the country has just 43 state-run mental hospitals and the District Mental Health Programme (DMHP) is limited to just 123 of the 650 districts in the country.
Criminal neglect and the inhumane and degrading conditions of such institutions was once again exposed recently when volunteers of an NGO in Kolkata went to the media with photographs of inmates of a Mental Health Hospital in Behrampore, West Bengal, being kept naked for months together. The National Human Rights Commission has intervened in the case. In an earlier case the NHRC had issued strictures against the Pavlov Hospital, Kolkata, where too women inmates were kept nude. There have been complaints of inmates of institutions, including those being run by some NGOs, being subject to all sorts of abuse including sexual.

Care in community based establishments, half way homes etc are better options and need to be strengthened.

Estimates suggest that around 6-7 percent of the Indian population have varying degrees of mental health issues. To treat such a big populace with psychosocial disabilities, there is a huge dearth of trained professionals, both in the government and the private sector. The WHO estimates that the treatment gap for mental illnesses in developing countries like India is as high as 90 percent.

In response to a question in the Lok Sabha asked by CPI(M) MP, M B Rajesh, the ministry of health and family welfare said that there are only 1417 psychiatrists in the government sector and 2410 in the private sector in the entire country. For a country with a population of above 133 crore (as of July, 2016) there are only 3827 psychiatrists (government and private included), which averages to one psychiatrist per roughly four lakh population.

Taking cognisance of this acute shortage, the Bill mandates the government to put in place training programmes to achieve internationally accepted norms in the next 10 years. This does sound ambitious. In the interregnum, the government has to train all medical officers in public health facilities to provide basic and emergency mental health care. The Bill lays down that mental health services should be integrated into general healthcare services at all levels of health care including primary, secondary and tertiary healthcare and in all health programmes run by the government. As of today even states with good district hospitals do not offer regular psychiatric outpatient services, leave alone in-patient facilities.
Another welcome feature is the provision made for insurance coverage to those with psychosocial disabilities.
The use of Electro-convulsive Therapy (ECT) has been one of the most controversial aspects of treatment methodology. “Shock” therapy, as it is commonly known, is banned in various countries around the world. Mental health activists have been demanding a ban on its use in the country. The Bill however, permits the same for adults but only with the use of muscle relaxants and anesthesia. Questions about whether it would still be less cruel or degrading remain.

Regulatory mechanisms
The Bill provides for regulatory mechanisms in the form of Mental Health Review Boards at the district level, consisting of a district judge, psychiatrist and users and care-givers to ensure that rights of persons with mental illness are respected when they receive care and treatment.
Mental illness has been used as a ruse for securing divorce, depriving people of property and inheritance etc. There are innumerable cases where people have been falsely diagnosed to be ill to enable family/relatives to bundle them off to institutions and get rid of them.  
Currently, families, legal guardians, and child welfare committees can admit persons with psychosocial disabilities to institutions without their consent. If found wandering on the streets, they may also be picked up by the police and admitted to these institutions. Many of them cannot seek any redressal. In this context the entitlement to free legal services to exercise any of the rights contained in the Bill, is noteworthy.
“Advance Directive” provides for a person to decide on the manner in which he/she should or should not be treated; right to appoint a person as his nominated representative etc. Though this may sound progressive, this has to be placed in the Indian context where it is not common for even those who own property to write their wills.
We are talking about a country where many of those undergoing treatment and their caregivers, especially in the rural areas, even while being informed about their medication, are unaware of the exact diagnosis or the terminology used to classify their illness.
Moreover, superstitious beliefs still rein supreme. Often people are taken to tantriks and places of worship in search of cure. The Chotanikara temple in Ernakulam district of Kerala is one such place. Many families take their relatives to this. Apart from other rituals some are made to hammer a nail into a tree within its complex either by hand or their forehead.
Besides, who will sensitise such persons on the provisions contained in the Bill and the options available for treatment, is a big question. Some activists are also apprehensive that this provision may be used to deny treatment.
The rights and policy directives contained in the Bill can become real only if they are accompanied by adequate budgetary support. Budgetary allocations for health care by themselves are very low. Out of this, a mere one percent is set aside for mental health. This has to change if the provisions of the Bill are to be meaningful and universal access to mental health care is to become real. How does this fit in with the neo-liberal paradigm?