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 Table of Contents    
GUEST EDITORIAL  
Year : 2019  |  Volume : 61  |  Issue : 10  |  Page : 637-639
Mental Healthcare Act 2017: Preface to the supplement


1 Department of Psychiatry, St. Thomas Hospital, Changanacherry, Kerala, India
2 Department of Psychiatry, Spandana Health Care, Bengaluru, Karnataka, India
3 Department of Psychiatry, Government Medical College, Kollam, Kerala, India

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Date of Web Publication8-Apr-2019
 

How to cite this article:
Ameen S, Gowda M, Ramkumar G S. Mental Healthcare Act 2017: Preface to the supplement. Indian J Psychiatry 2019;61, Suppl S4:637-9

How to cite this URL:
Ameen S, Gowda M, Ramkumar G S. Mental Healthcare Act 2017: Preface to the supplement. Indian J Psychiatry [serial online] 2019 [cited 2019 Jul 23];61, Suppl S4:637-9. Available from: http://www.indianjpsychiatry.org/text.asp?2019/61/10/637/255579




India became a signatory to the United Nations Convention on the Rights of Persons with Disabilities on May 3, 2008, and was in an obligation to update the existing mental health legislation and disability laws to ensure that they uphold the human rights during the delivery of treatment and care. As a result, the Department of Health and Family Welfare set the ball rolling, and the job was assigned to Indian Law School, Pune, India. After numerous consultatory meetings, the draft went through multiple revisions, and finally, we got the Mental Healthcare Act (MHCA) 2017 with the President's assent on April 7, 2017.[1] Both the ruling party and the opposition were united on this common agenda and passed the bill without any hesitation, spurring much debate on whether the move was a mere political expediency with little thought given to the resource commitments or whether it was indeed in the true spirits of the vision of “mental health for all by 2027.” The country was thus bestowed with “the world's best piece of mental health-care legislation” even as the broader and basic challenges such as clean food, safe water, nonpolluted air, socioeconomic backwardness, and lack of general health insurance remain only partially addressed. The strong, rights-oriented law promises to help every citizen of this country avail quality mental health care and services at international standards within the next decade.

The Act provides every person the right to access mental health care from services run or funded by the government and obligates the government to make sufficient provision of services for people with mental illness (PMI). It also entitles free treatment through government facilities for PMI who are living below the poverty line or are destitute or homeless. The government will need to augment or invest anew in a wide range of services such as halfway homes, sheltered accommodation, supported accommodation, community-based rehabilitation, day care centers, and quality psychiatric services at prisons, in addition to ensuring wider geographical distribution of mental health treatment facilities and access to essential psychiatric medications. The government will have the responsibility to create adequate human resources, trained mental health professionals (MHPs), innovative policies, and lucrative pay packages to retain the trained MHP human resources in the country; to conduct MHCA educational programs for PMI/caregivers/other agencies involved in treatment; and to provide effective rehabilitation for persons who attempted suicide under severe stress.

MHCA makes it explicit that PMI are capacitous unless declared otherwise by assessments and that therefore they can independently decide on the nature of treatment they wish to undergo, its duration, and whether they would like to be an outpatient or an inpatient. They are legally empowered to make their choices even when they are incapacitous, through their advance directive (AD) and also decide who will be the Nominated Representative (NR) that will undertake the caretaker role. Admissions under section 86 (independent admission) are done with the written consent of PMI, and discharge is possible anytime on request by PMI. The MHPs have been assigned the responsibilities of maintaining basic records and providing the same on request within the specified time, ensuring that their treatments match international standards, following their clients' registered ADs, and making effective discharge planning to ensure a smooth transition into the community. Utmost care is to be taken to protect the rights of PMI and to provide treatments in the least restrictive environment. Any disagreements PMI have with the MHPs during treatment delivery will be addressed by the Mental Health Review Board.

MHCA urges the MHPs to follow international standards. However, providing international standards in our setting will necessitate a change in work culture and increased system level resource allocation to reach those standards. For example, the additional workload of increased documentation, if not thoughtfully addressed during the implementation phase, can strain the working pattern of existing human resource who are handling a large volume of care seekers.

The effective implementation of MHCA 2017 requires adequate infrastructure, trained MHPs, coordinated work between the government, private, and the nongovernmental sector and a strong political will to make the required provisions of the law into a reality. A conservative estimate of the cost for materializing universal access to mental health care and implementation of the MHCA has arrived at a figure of about Rs. 1 lac crores.[2] This will require resource mobilization at the governmental and nongovernmental level. By bringing mental illness under the purview of medical insurance, MHCA envisions a potential expansion of service provisioning in the nongovernmental sector. The current budget allocation available for this mission is about Rs. 753 crores allotted for National Mental Health Program [3] and additional funding for central and regional institutes and other facilities under state governments. Thus, with the need for a major increase in governmental allocation toward mental health care, it is critiqued how the implementation of the MHCA provisions in a resource-deprived country like India will be feasible. Even after about two years of the MHCA 2017, we are yet to see the same united political will in the form of setting up the required human resources or infrastructure, or the provision of financial resources, to make this Act gain the momentum of implementation. The whole world is watching this ideal Act in its implementation stage in India, to learn from our mistakes and then incorporate suitable changes in their laws.

As a well-conceptualized initiative of the Indian Psychiatric Society (IPS) South Zonal Branch, a 3-day conference was organized at Tirupathi in October 2018 under the able guidance of Dr. TP Sudhakar and Dr. A Jagadish, where many significant issues concerning MHCA 2017 were deliberated. A special supplement on MHCA was planned with the aim of generating enough material to help the psychiatrists of the country practice the specialty effectively and safely in an era of changed laws governing patient care.

In this supplement, an attempt has been made to answer some fundamental questions: How right is rights-based legislation? Is it the right time for Community Treatment Orders? Are there alternatives to restraints? Can we have restraint guidelines? Do psychiatrists need a code of practice? Is Hippocratic Oath still relevant in the current era of legalities?

The interface of MHCA and patient care can happen at various levels, and we tried to understand the aspirations of the Act so that it can be implemented effectively, the challenges and opportunities the Act brings with it, the issues related to starting an MHE, formation of state rules with minimum norms for MHE, how to deal with statutory authorities during inspections and audits, the enormous economic impact the Act would have on the government and private psychiatric care, and the game changer of providing insurance to PMI for the first time in India.

We have articles which discuss changes introduced to the procedures for admission to MHEs; the process of obtaining informed consent; reorientation about the decision-making process; issues related to the newly introduced concepts of AD, NR, capacity assessment, and discharge planning; and newer documentary procedures.

The relevance of ethics, reorientation of postgraduate training, leveraging technology in the context of MHCA, the enigma of the doctor–patient relationship, issues surrounding the process of certification, issues related to dispensing medication by registered medical practitioners, penalties and liabilities to treating psychiatrists as introduced in MHCA, rights of persons with disabilities, and ways to prevent violence against doctors are discussed to give practising psychiatrists sufficient clarity about their role in an era of highly legalised psychiatry.

The treatment of patients with addiction or suicidal intent, care of homeless persons with mental illness, and issues specific to the management of the special populations of children and older adults, under the lens of MHCA, have been visited. Learning experiences from the United States legislation and the practical difficulties anticipated in the implementation of MHCA 2017 are covered. Finally, the apprehensions of the helpless caregivers in dealing with the very powerful rights now bestowed on those groups of patients who lack insight but have a retained capacity, and the lost role of families in the MHCA are discussed. We hope that this supplement intended to educate MHPs and others involved in mental health care helps in the effective implementations of the MHCA in the Indian realities.

The articles presented here are the professional opinions and interpretations of the gazetted law by the contributors who are specialists in mental health-care services delivery in India, with the help of available scientific evidence and are subject to legal clarifications. The discussions and articles here need not necessarily reflect the opinion of IPS or its journal.

The services of Dr. Suresh Bada Math need a special mention here for spearheading the campaign on education, critical appraisal, and implementation aspects of MHCA.

Special thanks to the editorial team, the reviewers, the authors, the office bearers and executive committee members of IPS and IPS South Zonal Branch, the publisher, and the advertiser.



 
   References Top

1.
The Mental Healthcare Act; 2017. Available from: https://www.prsindia.org/uploads/media/Mental%20Health/Mental%20Healthcare%20Act,%202017.pdf. [Last accessed on 2019 Mar 27].  Back to cited text no. 1
    
2.
Math SB, Gowda GS, Basavaraju V, Manjunatha N, Kumar CN, Enara A, et al. Cost estimation for the implementation of the mental healthcare act, 2017. Indian J Psychiatry 2019;61:S650-9.  Back to cited text no. 2
    
3.
Ministry of Health and Family Welfare; 2015. Available from: https://mohfw.gov.in/sites/default/files/55316202611436263831_0_0.pdf. [Last accessed on 2019 Mar 27].  Back to cited text no. 3
    

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Correspondence Address:
Dr. Shahul Ameen
Department of Psychiatry, St. Thomas Hospital, Kurisummodu Post, Changanacherry - 686 104, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_216_19

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