Saturday, April 30, 2016

Indonesia - Mental health laws would diminish stigma and improve the lives of millions

I have seen the negative impact of the UN’s failure to incorporate mental health within the millennium development goals (MDGs). Working on various mental health projects in several African countries, I saw how the health budgets of resource-strapped countries were diverted towards MDG projects. Many NGOs providing essential community psychiatric support were near collapse, or forced to alter their objectives to secure sufficient funds.

While almost half of the MDGs focused on physical health, mental health was conspicuously absent even though, at the time, approximately 450 million people worldwide were living with a mental illness. The UN sidelined mental health even though mental impairment falls within its own definition of “disability” in the convention on the rights of persons with disability (CRPD).

By 2030, the final year of the sustainable development goals (SDGs), depression is predicted to be the world’s biggest medical burden, and over the next 20 years the cumulative lost economic output due to mental illness will be $16tn (£11tn). However, only a few countries devote more than 10% of their total health budget to mental health.

Happily, mental health is included in the new SDGs, even if the word “mental” does not actually feature. Goal 3 seeks to “ensure healthy lives and promote wellbeing” for everyone – a significant improvement. Unfortunately, this loose phraseology will inevitably result in competition for international funding between mental health NGOs and other organisations with missions in sport, nutrition or the arts, for example.

It is also disappointing that only two of the 13 targets under SDG3 – 3.4 and 3.5 – relate to mental health, and that in the final global indicators (pdf) relating to the goal, only two of 26 are specific to mental health. One of the provisional indicators which would have required data collation on service use by those with severe mental disorders, mirroring a provision in the WHO mental health action plan (pdf), did not make the final cut. This was hardly the parity those working in mental health had hoped for.

But mental health has never had parity with physical health. Despite compelling economic arguments for investing in mental health, stigma perpetuates the lack of resources allocated.

So what can be done? A mental health law which enshrines the rights of those with a mental illness and gives them the right to treatment could help diminish stigma by educating people about human dignity and rights, in addition to protecting and empowering patients. A law can also frame policy, encourage prevention strategies, and set minimum skills for accreditation of mental health professionals and psychiatric facilities. While the UK’s 1983 Mental Health Act is far from perfect, it has done much to realise the rights of the mentally ill.

Nearly two thirds of the world either has no mental health legislation or has a law more than ten-years-old, and the 2030 agenda does not require the implementation of mental health legislation to enforce obligations, such as the right to access appropriate treatment.

Furthermore, for mental health legislation to have any real effect, there must be the political will to support it. It can be difficult to persuade low-resourced countries to do this, especially when there are many other pressing health problems.

Even where legislation exists, a patient’s ill health may prevent access to legal redress for human rights violations. Healthcare workers should inform patients at regular intervals of their rights under a statute. The procedure for challenging failures in implementation or non-compliance with legislation must be simple and clear, and ideally free legal assistance should be provided. To comply with international treaty obligations and best practice, an independent body to hear inpatients’ appeals against the removal of their liberty must be established.

Naturally, this requires significant funds and the global community can make a huge impact by funding the development or amendment of a law, legal expertise, training for local lawyers, advocates and healthcare workers, as well as independent monitoring and impact evaluation.

The good news is that there is finally a real drive to move mental health from the margins into the mainstream of the global development agenda. This month, the World Bank and the WHO co-hosted a high level meeting on global mental health (pdf) and development priorities, seeking parity between mental and physical health (appropriately headed Out of the Shadows).

If nations comply with the CRPD and other international human rights treaties, we’ll be able to see evidence that SDG3 and SDG16 are being met. Meanwhile, mental health lobbyists should press for additional indicators on SDG3 to measure mental health improvements – in particular an indicator requiring the introduction or updating of mental health legislation.

The global community must ensure that those with mental illness are not left behind. The world has a duty to spearhead positive change, and to prevent the continued marginalisation of the mentally ill. Let’s not miss this opportunity.

Laura Davidson

Laura Davidson is barrister and international development consultant specialising in mental health and mental capacity law.

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