IN a promising move last week, the National Commission for Human Rights (NCHR), in collaboration with Taskeen Health initiative, UNFPA and British Asian Trust launched a thoughtful Malpractice in Mental Health in Pakistan: A Call for Regulation report. The drafting of the report was spurred by a complaint registered at the commission regarding a 35-year-old woman who had been forcefully detained in a private facility in the federal capital for nine days. This was followed by a four-month detailed investigation involving the Ministry of Health, District Health Office, Inspector General Police and Islamabad Health Regulatory Authority. It transpired that at the time of the complaint, the private facility in question was not even registered with IHRA (despite functioning since 2019); had no full-time psychiatrist but still offered 20 beds for in-patient care; and relied on a process of assessment and treatment termed ‘ethically murky’.
The report goes on to shine a light on ineffective extant legislation, scarce and inequitable mental healthcare services, and unregulated practices, each painstakingly documented with horrifying verbatim examples. Although none of these findings are really surprising, this is the first time that these have been published by a statutory body which also has a watchdog and advisory role to the government of Pakistan.
That a ‘right to health is a right to life’ is the strongest value that underpins our Constitution was reiterated by Justice Syed Mansoor Ali Shah at the report’s launch event. Justice Shah was clear that the Constitution is not just for the able-bodied and healthy; it is, in fact, even more so for the vulnerable and disadvantaged. Quoting Articles 4 (law for the protection of every citizen), 9 (right to life) and 14 (right to dignity), he added that ‘citizen’ includes a person with mental illness or mental disorder. It is, therefore, a duty of the state to ensure dignified medical protection and care based on best practices.
The primary right of a citizen with a mental disorder is to have access to essential services. But existing mental healthcare in the country remains limited to tertiary hospitals, most of which are arranged in urban clusters. The integration of mental health into primary healthcare, as recommended by the WHO, has yet to be initiated in Pakistan. This should be the foremost obligation of the state. The promotion of positive mental health, prevention of risk factors such as drug use, gender-based violence, sexual and physical violence towards children, early detection of mental illness, suicide prevention strategies and psychosocial support in humanitarian crises such as the present floods, all require a robust community-based mental healthcare system.
The primary right of a citizen with a mental disorder is to have access to essential services.
The NCHR’s report recommends that federal and provincial mental health acts be updated to rights-based legislation and that they be enforced as a priority. Since this legislation has not been implemented for almost two decades, it is imperative that the causes for this inertia be carefully examined. In short, it is possible to identify 10 reasons for our collective failures on this front.
Mental health legislation only provides a framework for implementing the values and objectives of mental health policies and plans. In the absence of the latter, it is highly unlikely that the appropriate legislation can be implemented.
Mental health is not currently a health priority in Pakistan. Also, effective legislative implementation requires a robust multi-sectoral response, much beyond the capacity of our existing ministries of health.
Extant provincial legislations all derive from the Mental Health Ordinance 2001, the draft of which was based on the UK’s Mental Health Act of 1983. Pakistan cannot compare with the established systems and plentiful resources of developed countries like the UK. Thus, setting up an effective monitoring and regulatory system in a system of fragmented healthcare is just not viable.
Our existing facilities are already exhausted. Unless services are reconstructed and reconstituted, so that the burden of common mental disorders is managed in primary care, these are unlikely to have the capacity to take on further clinical and logistic responsibilities.
The healthcare system faces serious governance issues, including corruption. These conditions make it harder to challenge the status quo.
Mental health is closely determined by a combination of social, economic and environmental factors. It would be incorrect to think that legislation can in and of itself help protect mental health without addressing the larger context of these challenges.
Since hardly even a single goal has been achieved as a result of existing legislation, it is perhaps time to realign expectations and draw out a more realistic legislation which can be implemented in phases.
Mental health legislations are primarily standards for the protection and promotion of the rights of persons with mental health conditions. There is no point regulating services in the absence of progressive curricula, good practice guidelines and scientific protocols.
The process of accountability begins when service users are empowered to question, are made aware of recommended practice guidelines and have the liberty to choose their psychiatrists. This will only happen when alternative scientific and ethic models of care are made available.
Any effective implementation of mental health legislation requires the support of other agencies outside health, such as law enforcement, social services, and rehabilitation services. Unfortunately, these support structures are also not reliable.
In light of these arguments, it is important to focus on developing quality care and effective services based on internationally recognised standards. In this regard, the Mental Health and Psychosocial Support model developed by the Ministry of Planning, Development and Special Initiatives in 2021 deserves immediate attention considering that one in seven Pakistanis has been adversely affected by the recent floods. The path-breaking but sadly delayed project developed over the course of the pandemic offers a comprehensive multilayered, rights- and evidence-based model. It does not require unrealistic resources. It is also scalable. It can help address many of the concerns highlighted and would be a step in the right direction towards the protection of the basic rights of a highly vulnerable population.
The writer is a consultant psychiatrist and was part of drafting the Mental Health Ordinance 2001.
Published in Dawn, September 2nd, 2022