State's Negligence in Mental Health Care Highlighted by Supreme Court Ruling

Kathmandu. 'Rambadur' (name changed), a 35-year-old from Dhading, has been battling severe depression and anxiety for the past five years. 

Sometimes lost in thought, sometimes inexplicably scared, Rambadur's father brought him to Kathmandu for treatment three times. Met in Patan, Lalitpur, he softly narrated his son's problem.

Rambadur's father spoke in one voice about the harassment, hassle, and financial burden of coming from the village to Kathmandu. 'The government has not included this problem in insurance, which is causing us financial burden,' Rambadur's father told Ratopati. 'There is a health post in the village, but only paracetamol and ORS are available. There are no psychiatrists or counselors who understand my son's mental problem. 

Til Bahadur Saud (name changed), who came from Achham for his daughter's mental treatment, has been experiencing the hassle of going to the mental hospital for the past six years. Along with the financial burden, he has also been experiencing mental anxiety for the past year. Met near the mental hospital, he said with a sigh, 'The government has never been there for the poor; it has always been suffering and harassment. The court has issued an order for us, but it seems the government still doesn't consider our daughters' generation as citizens.'

Although the Supreme Court ordered the appointment of multidisciplinary manpower (psychiatrists, psychologists, psychiatric nurses, mental health social workers, psychotherapists, etc.) in all hospitals under federal and provincial governments and to start inpatient and outpatient mental health services, Til Bahadur's daughter has not yet been able to receive that service in the village.

It has been two years since the Supreme Court ordered to make the teaching and learning related to social workers and psychologists involved in mental health practical and to pave the way for service entry by making necessary arrangements for permits. Rambadur and Tilbahadur have to wait for months for mental illness treatment in government hospitals, and they cannot afford private ones. 

Two years ago, when Tilbahadur heard the news of the Supreme Court's historic verdict on mental health, he felt a glimmer of hope. The verdict stated—'Establish a mental health mechanism at the local level, allocate budget, and include it in health insurance.' 

But no change was seen in the health sector. 

What was that 'historic' verdict of the Supreme Court?
On November 17, 2081 (Bikram Sambat), a bench of Supreme Court Justices Hariprasad Phuyal and Nripadhwaj Niroula issued a 12-point directive order regarding mental health, which is considered the most significant verdict in Nepal in the field of health rights.

'The full text of the verdict stated, 'The order has been issued to establish a separate Mental Health Division under the Ministry of Health and Population/Department of Health Services at the federal level and a Mental Health Branch under the Directorate of Health at the provincial level, and to appoint and operate units/contact persons at the district hospital and district public health office level as soon as possible, by revising the National Mental Health Policy, 2053, to be compatible with the current federal system.'

It has also issued a directive order to revise the National Mental Health Policy, 2053, and issue a new Mental Health Policy, incorporating sufficient strategies to implement the right to mental health inherent in the right to health guaranteed by the Constitution of Nepal. Similarly, the Supreme Court issued a directive order to create an environment where individuals suffering from mental health problems can receive necessary medication and treatment by managing structures, budget, and human resources at an equal level with the field of physical health.

The full text of the verdict clearly states to revise the old policy of 2053, allocate a separate budget for mental health, and give it priority equal to physical health. But unfortunately, this binding order of the Supreme Court is gathering dust in government offices.

Furthermore, it has issued a directive order in the name of the government to qualitatively and quantitatively increase structures, budget, and human resources by considering the nature of problems in the field of mental health in the annual budget allocation and to move towards their solution. Similarly, a directive order was issued to the government to take necessary actions for the construction of specific laws related to mental health, including a mandatory provision for allocating a certain percentage of the budget of the overall health sector to the field of mental health, to ensure equal treatment for mental health services as physical health.

The Supreme Court ordered to link mental health services with community services provided by local governments, health insurance, disability cards, employment, and related services under federal and provincial governments. It also stated that since mental health is a public health issue, awareness programs should be conducted to reduce and end the stigma in this field. It was stated that necessary penalties should be imposed by considering such acts as offenses to remove the stigma and discrimination in the field of mental health.

It was also ordered that for providing quality mental health services, arrangements should be made for social security and self-employment promotion and management for individuals affected by mental health problems who are dependent and taking shelter, in accordance with the concept of community-based rehabilitation, to reintegrate them into their own families and communities. The court also issued an order to adopt alternative treatment methods such as Ayurveda and Yoga in the field of mental health and make necessary arrangements for lifestyle changes.

The full text of the verdict clearly states to revise the old policy of 2053, allocate a separate budget for mental health, and give it priority equal to physical health. But unfortunately, this binding order of the Supreme Court is gathering dust in government offices.

Implementation Failed 

Gajendra Bahadur Singh, Director General of the Department of Implementation of Verdicts, said that the mandamus must be implemented. 'The government may face legal consequences for non-implementation,' he said, 'If implementation is impossible, review or reconsideration can be sought in the court with concrete grounds. Otherwise, there is no alternative to obeying the order.'

Stakeholders have strongly objected to the government's indifference to the non-implementation of the Supreme Court's verdict. Supreme Court Registrar Manbahadur Karki questioned at an interaction on Tuesday, 'After the court gives a verdict, the state bodies should automatically start implementing it, but here there is a tragic situation where we have to remind them repeatedly. Otherwise, why is the court needed?' 

He stated that although state bodies should proactively implement court verdicts, court orders are not prioritized.

Gajendra Bahadur Singh, Director General of the Department of Implementation of Verdicts, said that the mandamus must be implemented. 'The government may face legal consequences for non-implementation,' he said, 'If implementation is impossible, review or reconsideration can be sought in the court with concrete grounds. Otherwise, there is no alternative to obeying the order.'

What happens due to non-implementation? 
Due to the lack of mental health services at the local level, depression and other problems are becoming severe, the ultimate result of which is suicide. The lack of psychiatrists, insufficient budget, services targeting the elderly, lack of quality treatment, increasing rate of suicide, and ineffective community referral system for patients are challenges in mental health prevention. According to one statistic, 8,000 people in Nepal commit suicide annually due to mental health reasons. 

As the government has not fully integrated mental health into health insurance and social security, poor families are falling deeper into poverty due to treatment costs. 

Due to the lack of budget and manpower, the inhumane practice of confining many mental patients in cages or tying them with chains still persists. Although the court has made discrimination in mental health punishable, due to the absence of law, patients still face the tag of 'mad' and rejection in society, say the relatives of the patients. Due to the lack of psychiatrist and psychologist positions in hospitals, patients are not receiving specialist services.