Safeguarding the Rights of Mentally Ill: Experience from Sri Lanka

Sherva Cooray Consultant Psychiatrist

Global Mental Health: Learning from Low and Middle Income

(LAMI) Countries

International Congress of the Royal College of Psychiatrists 24th-27th June 2014

Acknowledgements-

Dr Jayan Mendis,

Director,

NIMH (National Institute of Mental Health)

Sri Lanka

Presentation Outline

• Background Issues

• Sri Lanka and Safeguarding Mental Health-

yesterday, -today ...and beyond...

• Key achievements- omissions- commissions

• The Diaspora-RCPsych-Sri Lanka – towards achieving excellence

Sri Lanka-About...

• Population ~ 20,000,000

• Emphasis: prevention and public health

• Life expectancy 70 years++: Exemplary (WHO)

• Country of Contrasts-(???Mental Health)

• Man made & Natural disasters-

Viz. Ethnic and civil unrest latter 20th Century-2009,Tsunami 2004

Sri Lanka-About: History

• Healthcare-5000 Years-RAVANA

• First Hospitals established-4th Century BC- (Pandukhabhaya)

• Community Care

• Holistic system- mind and body(eg. Ayurveda)

• 1505 AD- Colonial system

Healthcare in SriLanka-Post colonial-1948-

• Very high standards of health development-(WHO)

• 2% of Gross Domestic Product (GDP) Public Health

• Free Universal Healthcare- Womb to Tomb-

• ~ 60% of the rural population relies on traditional and natural medicine for their primary health care

Sri Lanka-Mental Healthcare • Ranks among highest suicide rates in the world

1995= 47/100, 000*

2009= 19.6/100,000* *DeSilva, V et al 2012

Yet

• MENTAL HEALTH IS AN “ORPHAN”

• Archaic Mental Health Legislation-(Lunacy Ordinance of 1873-

• minor modifications in 1956

Violence against women is prevalent in Sri Lanka*

• 36% of ever-partnered men reported perpetrating physical and

or sexual violence against a female intimate partner.

• 6%of all men perpetrated sexual violence inclusive of rape against a non-partner woman

• 17 % perpetrated sexual violence inclusive of rape against any women.

Despite

• 1st Asian queen regnant-(47 – 42 BC): Anula-Black widow-serial killer

• First woman Prime minister-1960- Sirimavo Bandaranaike

*Broadening gender: Why masculinities matter -2013

The Tsunami 2004...and Aftermath

• Mental Health Policy-2005

• New Mental Health Legislation- drafted 10+ Years ago!

• Passed by parliament-2014

• WHY DELAY???

Safeguarding-Principles and Sri Lanka: ? Emerging Green shoots

• Principle 1 – Empowerment

Presumption of person led decisions and consent

• Principle 2 – Protection

Support and representation for those in greatest need

• Principle 3 – Prevention

Prevention of neglect harm and abuse is a primary objective.

• Principle 4 – Proportionality

Proportionality and least intrusive response appropriate to risk

• Principle 5 – Partnership

Local solutions via services working with their communities

• Principle 6 –Accountability

Accountability and transparency in delivering safeguarding

Mental Health Policy Sri Lanka 2005-2015-Highlights

To provide mental health services

• Universal High quality-Evidence based where and when needed.

• Organized at community level with consumer participation.

• Linked to other sectors of healthcare services

• Culturally appropriate

• To protect the human rights and dignity of people with mental illness.

Mental Health Policy- 2005: Key Principles

1. Provide services- Primary, Secondary Tertiary Levels 2. community based– 3. Enshrine consumer participation. 4. culturally appropriate 5. protect human rights and dignity

Sri Lanka Mental Health Policy-Progress

•Approved by the Cabinet in November 2005-Updated 2010

•The Ministry of Health & WHO

Capacity Building

–infrastructure, –human resources development

-seeking technical assistance

-scientific support for training and –curriculum development

What of Sri Lanka? Low Priority-Why?

• Lack of awareness and knowledge about mental disorders

• The lack of knowledge about the extent of the burden/ Presence of cost effective interventions

• Stigma

• Misconceptions/Prejudices /Beliefs -causes and the nature of mental health conditions- “possession”-Weak/Lazy/ dangerous

• underinvestment in mental health services as well as a number of different human rights violations- Low human resources

Michelle Funk-WHO

Human Rights-Sri Lanka

• Party to the 4 1949 Geneva Conventions but not their additional protocols.

• Ratified a number of other IHL treaties, including the 1980

• Adhered to many human rights treaties (but not their verification mechanisms)

• 2 international Covenants and the 1989 Convention on the Rights of the Child and its optional protocol on the involvement of children in armed conflict.

Mental Health Services Distribution 2004-2012 Things they are a changing!

GBV Prevention Team- NIMH 011-2578234 Ext- 294

Dr Pushpa Ranasinghe GBV 2012 NIMH

Previous Seclusion Separate Seclusion areas

Grandma receives the injection Home Visits

Launched 16th December 2009

Mental Health Help Line-1333 – (NIMH World Vision Collaboration)

RAISING THE PROFILE Human Rights for People with Mental Illness

2008-

NIMH Sri Lanka

Opening of the Community Outreach

Clinic For

People with Mental Health Problems

Wadduwa, Sri Lanka

2008

Now managed by the NHS

Sri Lanka

2010-2012 Professor Rachel Jenkins Dr Sherva Cooray Dr Jayan Mendis

mhGAP Training 2013

Professor Sab Bhaumik Dr Sherva Cooray

Towards sustainable Capacity Building “The art of the possible”

PARTNERSHIPS – Sri Lanka-The Diaspora- RCPsych

• Education and Training

• Long Distance Mentoring-”Adopt” a Colleague/s

• Share Mutual Expertise-(Medical Partnership Initiatives)

• The MTI

• Sabbaticals

What did I learn?? A LOT...

and still learning

• There's more than one way to skin a cat

• Resourcefulness & Resilience trumps Adversity

• How did they do it???

• When “despondent-”

Bat SERENDIPITY

24/06/2014