Examining the Examiners: Empty Laments, No Accountability
Part II of my critical analysis of Parliamentary Standing Committee on Health and Family Welfare report on ‘Mental Health Care and Its Management in Contemporary Times’
This article is the second part of my review of the Report. You can read the Part I here.5. Mental Health Issues in Children and Youth
In its Report entitled ‘Mental Health Care and Its Management in Contemporary Times’, the Parliamentary Standing Committee on Health and Family Welfare has noted that according to the World Health Organisation, “around 8% of the world's young children (aged 5–9 years) and 14% of the world's adolescents (aged 10–19 years) live with a mental disorder.”
As per the National Mental Health Survey 2015-16 (NMHS 2015-16), 7.3% of children aged 13-17 years lived with a mental disorder, but the prevalence almost doubled to 13.5% in the cities.
The Committee did not ask the Government if it took any steps for the mental health of children and youth after the NMHS 2015-16, but recommended it to
run awareness campaigns to “educate citizens about the importance of mental health and the role of behavioural aspects” and “promote healthy habits, coping skills, and ways to seek help when needed”;
work with employers and schools to implement workplace wellness programs and mental health education for students, respectively;
“invest in research to better understand the behavioural aspects that impact mental health and the effectiveness of different interventions”;
add provisions in the second National Mental Health Survey (NMHS 2) to collect data on “mental health and psycho-social well-being of children, adolescents, youth and caregivers”;
train mental health professionals specifically to address mental health concerns of children and youth; and
develop “a dedicated cadre of school counsellors in all schools under the "Manodarpan" initiative”.
6. Rising Trends of Suicides in India
When the NMHS 2015-16 was published, the annual national suicide rate, as per the National Crime Records Bureau (NCRB), was 10.6 per one lakh population. In 2022, it reached 12.4, the highest since the Independence.
The Parliamentary Committee highlighted the leading categories of suicide victims such as men, students, farmers and agricultural labourers, daily wage earners, self-employed persons, and the employed, but did not mention the housewives, whose numbers are second only to the daily wage earners and who form the majority of female suicide victims.
This omission becomes even more glaring when you read the Committee’s this lament:
“The Committee notes that while more students committed suicide than farmers, the latter's suicides were termed a national crisis. However, suicides by students hardly caught anyone's attention and were dealt with on a case-to-case basis.”
The Committee recommended the establishment of a 24/7 helpline to counsel students who cannot qualify for competitive examinations.
Also, yes, the Report used the outdated language everywhere when referring to deaths by suicide.
Although the Committee took note of the National Suicide Prevention Strategy, it did not ask a single question about its implementation. Just another instance of it abdicating its duty to hold the government accountable and giving the latter a free pass.
Let us now turn to the Report’s Chapter II entitled Mental Health Policy and Legislation. In this chapter, the Committee analysed the National Mental Health Policy 2014 (NMHP 2014) and the Mental Healthcare Act 2017 (MHCA 2017).
National Mental Health Policy 2014
Launched in 2014, the National Mental Health Policy (NMHP 2014) is a landmark document focusing on values like equity, justice, integrated and evidence based care, participatory and rights based approach, and holistic approach to mental health. It lays special emphasis on stigma, poverty, homelessness, persons inside custodial institutions, orphaned persons with mental illness, children of persons with mental illness, care givers, internally displaced persons, persons affected by disasters and emergencies, adequate funding, support for families, inter-sectoral collaboration, and continued monitoring and evaluation of mental health of people.
As the 10th anniversary of the NMHP’s launch approached, the Parliamentary Standing Committee on Health and Family Welfare got a great opportunity in the form of this Report to evaluate its implementation by the Government of India and various state governments.
As the Committee noted, the following are seven strategic action areas of the NMHP 2014:
(i) effective governance and delivery mechanism for mental health;
(ii) promotion of mental health;
(iii) prevention of mental illness, reduction of suicide and suicide;
(iv) universal access to mental health services;
(v) improved availability of adequately trained mental health human resources to address the mental health needs of the community;
(vi) community participation for mental health and development; and
(vii) research.
The Committee begins its analysis of implementation of these strategic directions by declaring that “despite almost a decade since its introduction, the policy's progress has been limited” and “only a few states have embraced and implemented the outlined recommendations of the National Mental Health Policy”. It records that the execution of the Mental Healthcare Act, 2017 (MHCA 2017) and the National Suicide Prevention Strategy 2022 — brought on the recommendations of the NMHP 2014 — has been thwarted by the lack of budget allocations, and most of their provisions are still awaiting implementation.
On suicide, the Committee underlines that despite Section 115 of the MHCA 2017 decriminalising the suicide attempt, the police personnel were largely unaware of this provision and continued to file cases under section 309 of the Indian Penal Code. However, again, the Committee did not ask the Government why it had not implemented the Section 115 strictly.
For the proper implementation of the NMHP 2014 recommendations, the Committee recommended “formulating national and state-level action plan (s)”. Moreover, it said:
“The Committee further believes that the policy should be evaluated and reviewed periodically due to the constantly evolving landscape of mental health issues and the subsequent difficulty in implementing an all-encompassing policy like the NMHP.”
Guess who just dropped the ball when presented with an opportunity to evaluate and review its implementation?
Yes, the Parliamentary Standing Committee on Health and Family Welfare.
The Mental Healthcare Act, 2017 (MHCA 2017)
In 2017, the Parliament passed the Mental Healthcare Act, 2017 and it was implemented in 2018. The Act focuses on ensuring the protection of rights of persons with mental illness (PMIs) and mandates the governments to develop mental healthcare infrastructure for the realisation of these rights. The Committee evaluates several aspects of the MHCA 2017, beginning with the “critical examination” of advance directives.
Advance Directives
The Committee “believes” that for proper implementation of advance directives, both the public and professionals need to be made aware.
A great point, but then it says:
“Furthermore, the Committee believes that mental health conditions and circumstances may change over time, leading to alterations in an individual's preferences for treatment. The Act does not explicitly address the issue of periodic review and updating of advance directives. The Committee, therefore, recommends that regular review and the provision for modifying advance directives in response to evolving preferences and conditions should be considered to ensure their relevance and applicability.”
Did the Committee not read the Act before beginning its analysis?
Because its Section 8(1) says:
“An advance directive made under section 6 may be revoked, amended or cancelled by the person who made it at any time.”
Central Mental Health Authority (CMHA)
According to Section 43 of the MHCA 2017, the CMHA, inter alia, is responsible for
(a) maintaining registers of all mental health establishments, clinical psychologists, mental health nurses and psychiatric social workers in the country;
(b) developing quality and service provision norms for mental health establishments;
(c) training law enforcement officials, mental health professionals and other health professionals about the provisions and implementation of the MHCA 2017; and
(d) advise the Central Government on all matters relating to mental healthcare and services.
The CMHA was constituted in November 2018.
As expected, the Parliamentary Committee noted it was largely absent from public arena even after five years of existence and does not even have a website. From the Report, it appears that the Union Government told nothing about the CMHA, including its budget, to the Committee. That makes the CMHA as mysterious and mystical as the Research and Analysis Wing (R&AW) and the Intelligence Bureau (IB).
State Mental Health Authority (SMHA)
Under the MHCA 2017, the SMHAs are state level bodies with powers and functions similar to the CMHA. Unfortunately, their public presence and performance are also similar to those of the CMHA.
Although many states have established these bodies, the Committee noted, “efforts related to the appointment of ex-officio and non-official, appointment of CEOs, officers and other staff, development of mechanisms for complaints redressal and establishment of SMHA funds need further push in most of the States.”
The Committee recommended the development of a tracker “to track the implementation status of the establishment of SMHAs, MHRBs [Mental Health Review Boards] and other determinants governing the development of mental health infrastructure and human resources.”
Prisoners with Mental Illness
Section 31(2) of the MHCA 2017 mandates the governments to “train… all medical officers in the prisons or jails to provide basic and emergency mental healthcare” and section 103 provides for the procedure of treatment of prisoners with mental illness.
The Committee noted that as per the NCRB, 1.7% of total prisoners were living with mental illnesses as on December 31, 2021.
It recommended the Government to
(a) provide adequate training to the prison staff regarding mental healthcare;
(b) ensure that adequate mental healthcare staff is stationed in the prisons to address the needs of the inmates; and
(c) conduct periodic training programs for police, judiciary and general health practitioners to sensitise them about their responsibilities and provisions of the MHCA 2017.
Again, no questions about what the Government had already done or not done.
Mental Health Insurance
As you know, the Section 21(4) of the MHCA 2017 states:
Every insurer shall make provision for medical insurance for treatment of mental illness on the same basis as is available for treatment of physical illness.
To implement this provision, the Insurance Regulatory and Development Authority of India (IRDAI) has issued notifications from time to time.
The Report does not provide data on the insurance companies which have implemented this provision in their policies. It appears the Government gave the NDA (No Data Available) response to the Committee.
The Committee asked the Government to
(a) “develop a mechanism for monitoring the insurance delivery for mental health issues”;
(b) collect “data on policies covering mental health issues, total claims received for mental issues, total claims cleared, rejection of policies and reasons for rejection.”; and
(c) discourage the insurance companies from excluding outpatient services (such as counselling sessions) and treatment for suicide attempt from their policies.
Rights of Persons with Mental Illness (PMIs)
The Chapter V of the MHCA 2017 focuses on the Rights of Persons with Mental Illness, but the Committee has mistakenly titled the chapter as the Rights of Persons with Disabilities.
This Chapter, inter alia, establishes the rights of the PMIs to access mental healthcare and live with dignity in the society, right to protection from cruel and degrading treatment, mandates availability of mental health services in each district, and in case of the PMIs abandoned by their families, asks the government to establish “less restrictive community based establishments including half-way homes, group homes and the like for persons who no longer require treatment in more restrictive mental health establishments such as long stay mental hospitals.”
The Department of Empowerment of Persons with Disabilities told the Committee that it was running the scheme Deendayal Disabled Rehabilitation Scheme (DDRS) for establishing half way homes for rehabilitation of the PMIs. The Department was also working on rehabilitation of the PMIs “through vocational training, reskilling, and counselling beneficiaries and families to facilitate integration into families and society/community.”
The Committee recommended the government to
(a) expedite the establishment of half way homes and to ensure that the treated patients who “don’t require to stay in mental health establishments are not redesignated to old age or beggar homes”;
(b) establish vocational training centres in all districts and special employment exchange for PMIs; and
(c) develop “a portal for real-time display of half-way homes established in all states and UTs, their capacity and occupancy, the facilities provided and the mental healthcare professionals available.”
As with other provisions, the Committee did not ask the government important questions about the violation of rights of the PMIs as well.
Throughout the Report so far, the Committee has expressed only empty laments on the state of mental healthcare in India, but did nothing to hold the government accountable.
Further, surprisingly, or may be not surprisingly, the Committee did not even mention the National Commission for Allied and Healthcare Professions Act 2021 in the Report, despite the fact that a large majority of mental health professionals are mandated to be registered under this law.
Finally, perhaps the most alarming aspect of this Report is that the Members of Parliament saw only what the government showed. They questioned only those omissions and commissions which the government acknowledged. I can assert with reasonable certainty that none of the Committee members did any preparation before the meetings to question the government representatives. I can assert with even more certainty that no member read the Report before signing it.
If you don’t trust me, I leave you with this screenshot from the Report.
Next Tuesday, I will review the Chapter III entitled National Mental Health Programme and Mental Healthcare Infrastructure.