Mental Health Act, 2013: a mockery of Human Rights

Legislations are formulated to protect and promote the interest of the individual and society. But sometimes these laws turn against the human beings and breach their fundamental rights. Such laws are based on utilitarian principle i.e. they focus on the interest of a large population at the expense of minors. So it is not necessary that if something is legal, it is also ethical. Mental Health act of our country is the illustration of such an unethical law.

                     People suffering from mental illness bears double burden of their illness and stigma associated with their illness. The pervasive impact of their illness echoes in every facet of their life whether it social, professional or economic. They are even abandoned by their family members. They face isolation and helplessness in their everyday life. The society remains ignorant to their needs. Their life is not less than virtual hell in the community. Their abysmal condition requires a legal framework to safeguard their interest. Ironically these mental health acts are violating the human rights of such people rather than protecting them. A predicament exists when we consider the mental health act in light of human rights. Traditionally, the purpose of any such law is to isolate the individual from the rest of society as they are considered as troublesome and dangerous for society.     

                           In India the first mental health act was formulated in 1858 through Indian lunacy act. Under this act, mental asylums were set up and mentally ill people were called as idiots, insane or lunatics. This Act was amended in 1912 and civil surgeons were put in charge of the mental hospitals instead of the Inspector General of Prisons. In 1987, mental health act was passed by Indian Parliament. This act has been criticized due to its main emphasis on promoting the institutionalization of mental health care and it also fails at its implementation level. Its implementation problem revealed after a fire accident in an asylum in Tamil Nadu in 2001.In this accident 28 people with mental illnesses were died because they were unable to run as their legs were tied to stone pillars. In 2007, India became signatory to the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). India under compulsion has to bring its existing laws into congruence with the basic principles of the UNCRPD.

                      As a result, India initiated the process of amending the mental health act, 1987. These amendments could have been a hope for people living with mental illness but unfortunately the new proposed mental health care bill, 2013 continues to approach a mentally ill person through his illness and not through his rights.

Now I will look critically at the proposed amendments in the mental health act from an ethical perspective.

1. The whole process of amendments was non-participatory and unfair. Neither the people suffering from mental illness have been informed nor has their voice been included in drafting a law that will determine their lives. Even the Nodal Ministry for the affairs of disabled persons and the Ministry of Social Justice and Empowerment were not consulted before formulating amendments.

2. The proposed definition of mental illness excludes the mental retardation. It puts an open ban on the treatment of all mentally retarded persons in psychiatric hospitals. Mentally retarded individuals require need care in total care institutions where a mental health care professional expertise is available.

3. The amendments overlook the individual’s right of autonomy. Any person who is 18 years of age or above and is competent can appoint a person known as “nominated representative (NR)”. The representative should be above 18 years of age. He/she helps the patient to interact with the mental health system and also acts as a legal guardian for the patient. A conflict with the autonomy of the patient will arise if the nominated representative does not act according to the patient’s wishes and most important is the issue of assessing the competence of a patient in appointing a nominated representative. There is no objectivity in assessing the competence of a patient rather it depends upon the decision of mental health professional.

4. One of the new amendments is the inclusion of the provision of “advance directives”. Every person, irrespective of their mental health status has a right to make a written statement known as an ‘advance directive’. The ‘advance directive’ is a legal document which provides the individual with the autonomy to decide the manner in which he/she wishes to be cared for during a future period of illness. There is a necessity to certify the competence of the individual in writing an advance directive. Again there is a lack of objectivity in assessing the competence of the individual in writing an advance directive. The provision of advance directive could come in conflict with “best interest principle”. A situation may arise in which choice of treatment is contrary to the treatment mentioned by individual in advance directive. This gives rise to a dilemma for mental health professional between right to autonomy of individual and principle of beneficence.

5. In proposed amendment, no legal process is required for admission and treatment of an individual in an asylum against his/her will. Anybody who is labeled as mentally ill by a mental health care professional can be admitted against his/her will. There are no empirical methods for establishing the validity of mental illness. The petition regarding involuntary detention would be heard only after 7 days .Even the criminals are produced before magistrate within 24 hours of their arrest.

6. These amendments are likely to cost human lives. It gives the authority to an individual who has not been trained to be a physician (psychiatrist nurse and social worker) to carry out role of independent examination, diagnosis and admission of patients in mental health facilities. Shortage of mental health professionals is given as an excuse for such unethical amendment.

7. According to the new mental health care bill, 2013 children with mental illness will come under this law instead of being treated as children in need of care and protection under the Juvenile Justice Act. This law gives the authority to a mental health professional to acclaim that a parent is not capable to be guardian of a child suffering from mental illness.

9. One of the proposed amendments is on the prohibition of certain treatment of mental illness. This amendment is based on principle of non-malfeasance. It poses a ban on electro-convulsive therapy (unmodified ECT) without the use of muscle relaxants and anesthesia. The conflict between principles of non-malfeasance and beneficence arises when a patient needs immediate electro-convulsive therapy in a life threatening situation. Moreover, modified ECT is not feasible in our country because of cost and infrastructure. Also serious adverse effects are very rare with unmodified ECT. Given this, a complete prohibition on unmodified ECT is unethical as it can be dangerous to the life of a patient.

10. No attention has been given to women suffering from mental illness. Mentally challenged women are often been marginalized when it comes to government strategies and rehabilitation plans. There is an increase in the number of parents opting for sterilization of their mentally challenged daughters.

11. The mental health care bill, 2011 don’t lay emphasis on universal capacity. None of the amendments talk about the capacity building of individuals suffering from mental illness so as to enable them to make informed choices regarding their life. Instead the law provides for proxy decision making by nominated representative.

12. These proposed amendments continue to lay emphasis on the institutionalization instead of the provision of community health care. Anyone can start a mental health institute. The penalty  for such institutes set up without permission are not deterrent enough, as there is only a fine of Rs 50,000 proposed on the first offense.

A dilemma exists between ethics and laws when it comes to mental illness. There are no easy answers to these ethical dilemmas. These amendments are anti-patient and can lead to abuse of a patient. There is a need to formulate these laws from humanistic and ethical perspective.

By- Dr. Sanjida Arora

MPH-SE (Social Epidemiology)

2012-14 Batch

TISS, Mumbai

The Companies Law 2013 and the healthcare sector

Introduction:-

With the president Pranab Mukherjee giving his assent to the new companies’ bill, making it into a law, it provides for many changes in the way our companies will operate and be regulated. The new law reckons much needed changes to the 1956 legislation enacted for the same purpose as it reflects the need of the hour in terms of the changing face of the Indian industry. The next stage in the process after the parliamentary approval and the presidential assent is the process of making the rules of the new legislation, the draft of which the corporate affairs ministry is expected to roll out in a couple of weeks.
Though broadly speaking the impact of the new companies bill on sectors like manufacturing, retail, the services sector in general are usually discussed, the ramifications of this law on the healthcare and hospital sector in particular also would be worthy to take look at.

First and foremost, the question of its impact on the hospital sector becomes interesting because of the slow shift that we have been seeing in the nature of ownership of the hospitals. When the hospitals of the yesteryears were mostly charitable in nature and were not strictly under the purview of the companies’ law, but with the corporatization of the healthcare sector many of these institutions would now come under the ambit of this law. Having said this it now becomes pertinent for the healthcare managers to be aware of the new law. Let us look at some of the new features of this law.

Spending on Corporate Social Responsibility:-

This has been the most talked about topic in the new law. According to the law all corporate entities are supposed to spend 2% of its average net profits during the three preceding on CSR activities. The nature of these activities may be but not restricted to activities that help the immediate neighborhood. The CSR spending has been included to encourage the companies to create a positive impact on the immediate social fabric through their existence in the society; it would be interesting to note how the corporates view it. Though the views of some of the people in this regard seem to range from looking at this as a mere additional tax or even if in a lighter vein, it can be said that if a large industrial house is running a hospital that in itself become a CSR activity, however the essence of this new law is in the point of inclusive growth in the society in which we are serving and whose resources we are utilizing to survive. Whatever might be the different ways in which we look at it, we need to understand that, especially in case of a hospital that even when run on a purely business model it should be able to serve the community in which it is located irrespective of various financial and social barriers that limit the people from seeking treatment. With the advent of this new law let us hope that it becomes an opportunity for the healthcare providers to do this better than taking it to be a statutory burden.

Women Directors:-
The new companies’ law also stipulate that there must be at least one woman on the board of directors. The healthcare industry in India is also no exception to the “glass ceiling” phenomenon that is seen in other sectors. This is evident from the fact that tough there are a sizeable number of women in the both junior executive positions and clinical roles; the number becomes a handful when it comes to the CXO and directorial positions. At least till a point where this virtual ceiling is broken a statutory requirement would ensure that budding woman mangers wouldn't be demotivated by the inbuilt incongruities of the system.

Tighter statutory Control:-

The bitter experiences of the Satyam episode and the way in which the various investment banks in the west went belly up almost bringing the global economy to a meltdown, seems to have played its part in the formulation of the companies law as it tries to rope in many of those grey areas which let many such serious financial frauds to be overlooked, at least initially. One important thing that has been envisioned is the statutory recognition for the Serious Fraud Investigating Office (SFIO). This recognition would give more teeth to this authority to subdue erring originations right from the beginning rather than deal with them when things go awfully wrong.

Another among the reforms included the responsibilities of the auditor has been increased and this is done to take the process of audit beyond the levels of "reasonable assurance”. For this some measures like appointment of a single auditor for a period of 5 years has been included. It also stipulates that one auditor can audit a maximum of 20 companies and the inclusion of a clause for imprisonment up to one year for misleading statements etc. are all expected to bring in more accountable audit process. Other important feature has been the inclusion of the class action suites which enables even the small investors in the company to question the various policies and stopping their interests being hijacked just because of their minority value of stockholding. To top it all a separate national company law tribunal has been setup, which would now mean a more focused judicial process will follow the legislation.
The most direct impact of the above is going to be to the insurance sector. Insurance sector in India has been very keen to tap into a very large market primarily through their participations in the government schemes like the RSBY. In a way insurance is poised today is akin to the IT sector in India and the financial services growth in the USA and the pattern of development is indicative of a Damocles sword hanging, some of the evidence of which can be seen in the recent allegations against a major insurance company of having the government to cough up crores as premium for ghost beneficiaries. It is the right time to bring in such regulations to nip some of these nefarious tendencies in the bud.

For Entrepreneurs:-
One of the new features of this law that would be of interest for the upcoming entrepreneurs is that it allows for a one person company. This is a welcome move for the fact that healthcare has become one of the hotbeds for spurt in entrepreneurial activities using various IT platforms and solutions which essentially opens up the possibilities of one person companies to a greater extent than ever before.

Another feature of the new law, though a one which would be one of the worst nightmares for any entrepreneur to encounter is that the employer is supposed to pay all employees 2 years of salary in advance on winding up of operations.

Conclusion:-
Though the complete ramification of the new law can only be fully understood after the rules are framed and it is executed, but in a nutshell we can surely say that the new companies bill is a right step in fortifying the functioning of the corporates and making them more grounded into the society in which they are. But as with all the laws in India, the execution is where it falters, let us hope that this new law provides a framework for improvement of our corporate ecosystem and it gets adapted in both letter and spirit.

By - Vivin George

MHA-Hospital Administration
2012-2014 Batch
TISS, Mumbai

Part One: - Quality Management in Healthcare: Past, Present and Future

The debate seems never ending when it comes to define and unfold the word Quality. Dilemma still exists regarding quality being subjective or objective, directly or indirectly associated with performance, and cost incurring or cost saving. It is also not very clearly understood that whether it is a responsibility of management or clinicians, and whether it is reactive or proactive in approach. Whatever the understanding may be in the industry, however it differs from place to place. One thing is for sure that Quality is major and decisive factor in almost each and every aspect of hospital performance. You name it and quality is there to make a difference. Aspects  like  patient  care,  better  outcome,  for  patient,  family  and  visitors, marketing of the hospital, workforce satisfaction, financial betterment and the list goes on when we try to assess the contribution of Quality in hospital functioning. For a second if we look beyond health sector, we are bound to find quality as a single most factor that helps organizations to stand apart and deliver the best with better performance from all aspects including operational performance and financial performance of an organization.

We would try to understand the things under following headings:-
1. Quality Journey of USA & India
2. Present scenario of quality in healthcare
3. Visualization of future with regard to quality


Quality Journey of USA
‘Improving quality will reduce expenses while increasing productivity and market share’. These words uttered by Deming while delivering lecture at the Mt. Hakone Conference Center in August 1950 changed the outlook towards quality. It started the never ending journey in the arena of quality. Japanese, in 1950s and after, indentified and reacted in a positive  manner  against  the  principles  suggested  by  Deming  and  in  his  home  country America it was Ford in 1980s that identified and implemented Deming’s principle in the business and got the competitive edge against GM and Chrysler. From this fundamental and thought provoking work, US secretary of commerce of the Reagan government, took personal interest during the difficult times of economic slowdown and came out with the Quality Improvement Act of 1987. Malcom Baldrige National Quality Award honours the contribution of the visionary towards high end performance via the medium of quality.
Currently Agency for Healthcare Research and Quality (AHRQ) of the US department of health and human services (HHS) is the main agency to develop, implement and monitor aspects of healthcare quality in US at national level. AHRQ's mission is to improve the quality, safety, efficiency and effectiveness of healthcare for Americans.  Also JCI, ASQ NAHQ and many more are non-government agencies that are contributing in building quality framework of US healthcare organizations.

Quality Journey of India
We had private sector as a major health care provider since beginning, yet we lagged behind in providing quality care. Two landmark years I would like to highlight here is 1983 and 2006. First Apollo group of hospitals came into existence at Chennai in 1983 and NABH became constituted body of QCI in 2006. IMC RBNQA (Ramkrishna Bajaj National Quality Award), adopted from Malcom Baldrige National Quality Award, was established in 1996. But RBNQA gave little importance to the healthcare sector until in 2008 when P. D. Hinduja Hospital won the RBNQA as a first Indian healthcare organization immediately followed by the L H Hiranandani Hospital very next year. As of now total 188 hospitals including public, charitable and corporate hospitals are NABH accredited. Still many applications awaiting the response from NABH body to assess the hospital. This can be described as a good response but it represents only a minute fraction (1.37%) of total hospitals in India (Total number of hospitals in India are 12760 as per CBHI). Indian counter part of Malcom Baldrige, IMC RBNQA is striving to achieve performance excellence through the medium of quality which can be assured by committed leadership, operations and workforce focus, strategic planning, knowledge management, patient centred approach and focus on overall results.

Present Scenario of Quality in Healthcare
It  is  high  and  good  time  that  we  have  started  to  view  quality  from  an  organizational viewpoint. It no longer remains a departmental activity but now it seeks to have commitment from each and every individual to contribute towards quality. It has transformed from retrospective to prospective approach and cyclic to process approach. Days are gone when quality  improvement  was  fault  finding  and  exercise  for  blaming,  it  is  now  a  way  of continuous quality improvement. It has altogether taken a new road map by aligning quality with the statistical progress. Now it has been widely and aptly accepted that things that we can’t measure, we can’t improve. Quality improvement is now more scientific way of achieving better results but yet not mandatory. Awards and reorganization still remains the major way of driving organization to work towards the quality improvement.  It is well established that organization incorporating the quality aspect and showing commitment from top management are bound to perform well in the industry.

Unfolding Future Opportunities
A lot lies in the future with regard to quality in healthcare.  Still somewhere we got to understand that we can directly as well as indirectly contribute to the quality. But time has come where we need to see each and every activity or process in the hospital has direct impact on quality.  There  won’t  be  anything  like  indirect  when  it  comes  to  quality  in healthcare. Quality dimensions range from leadership to customer focus, micro to macro level and so on. An era will come when we will establish linkage between effect of community, government, educational institute, socioeconomic culture and quality. We have to understand that  it  is  not  only  the  internal  environment  that  will  decide  the  quality  but  external environment will have the same impact in shaping the culture of quality. What I believe in is that the next generation will strive to shape the workforce in order to achieve the quality and better healthcare outcomes. No longer will it be viewed as a marketing tool but it will become a decisive tool for sustained business and business improvement. This can be achieved by the fabricating, embodying, internalizing in the culture of an organization what we can call as culture of quality. Quality culture will be the fabric of the organization which will be binding gel of an organization.
An era will come when price will no longer be a differentiating feature. No longer it will offer competitive edge or affect the choice of healthcare facility. At such juncture, quality will offer the competitive edge to the organization which can, not only ensure quality but communicate the same to the customer. Educated lot of customer won’t look at only the numbers or indicators to decide the level of quality care in the hospital, but they will look at and relate to the way organization will offer quality care. Next generation hospitals have to have unique roadmap in order to ensure better patient care experience and   to have better outcome. So let us all strive not for destination, but for the journey called quality to win the care taker and care giver and each and every stakeholder or an organization.

Dr. Biren Chauhan
MHA-Hospital Administration
2012-2014 Batch
TISS, Mumbai
birenc15@gmail.com

THE CHANGE MANAGEMENT.

"Life used to be so simple", lamented an independent logger." My father cut the trees, hauled them to a saw mill, and got paid.  The demand for wood was quite stable, the supply of trees was plentiful, and his logging equipment consisted of a chain saw, axe and truck. Life was good in those days.

"So what is different now?" the logger was asked.

"Absolutely everything", he replied. "Current logging rigs cost hundreds of thousands of rupees. I need Government permits for everything I do. Environmental groups protest against logging. Demand for my loggers fluctuates widely. And cut throat competition makes it tough for me to make a buck. I am not sure I can keep my head above water."

EVERYTHING CHANGES. The only thing permanent in universe is change. So to exist we need to adapt; we need to change. Unless we do that we fail to exist: we perish. So did a range of entities ranging from the mighty dinosaurs to thriving organizations.

Change management is being increasingly recognized as an important issue for organizational management. The world is not the same as it was 50 years ago or as a matter of fact 10 years ago or even 5 years ago. With changing times, people change, expectations change, circumstances change, trends change and so need an organization to change. Whether the change is positive or negative is very relative.

Factors initiating change-

·        Globalization

·        Increasing customer awareness

·        Increasing customer demands

·        Changing customer tastes

·        Changes in technology

·        Increasing competition

·        Increasing costs

·        Changing national and international policies and regulations etc.

TYPES OF CHANGE MANAGEMENT STRATEGIES IN ORGANIZATIONS

The change management can be continuous or dis-continuous.

Let’s illustrate it.

Let us look at a right angled triangle.

If A is the initial state of an organization and C the final changed state, we can arrive from A to C through 2 pathways. Either we can go along the sides of the triangle, i.e. from A to B and then from B to C or we can go along the hypotenuse of the triangle- directly from A to C.

For such a triangle, AB + BC > AC

AB + BC represents discontinuous change, AC represents continuous change.

We find that through continuous change we can achieve the objectives faster than through a discontinuous change. This forms the principle of Total Quality Management (TQM) through which organizations strive to achieve continuous improvement by continuous change.

NEEDS TO BE ANSWERED BY THE CHANGE MANAGERS OF THE ORGANIZATION. TO IMPLEMENT A CHANGE, THE FOLLOWING QUESTIONS FIRST

3 ASPECTS OF CHANGE MANAGEMENT

Change management deals primarily with changing 3 aspects:

1. Content               

2. People

3. Process

An example to illustrate it has been given below:

Change management for establishing computerised HMIS in a hospital

Changes should be smoothly and successfully implemented to achieve lasting benefits. For a systemic change management various models are followed, most popular of which are discussed below.

CHANGE MANAGEMENT & AESOP’S FABLES

The seeds of management can be traced back to the morals of Aesop’s Fables. Following are various stories whose morals teach us a thing about change management.

CHANGE MANAGEMENT IN HOSPITALS

Hospital processes have not dramatically changed over the years as to impact over-all patient satisfaction. It is common and ironic to see out-of-date management practices mixed with state-of-the-art medical equipment and sophisticated information technologies.

Factors initiating change in hospitals-

·        Changes in the hospital's operating environment and stakeholders

·        New government regulations.

·        Implementation of new technology in the hospital such as HMIS etc.

·        The increase in insured patients.

·        The high turnover of medical staff particularly nurses.

·        The increase in new hospitals in the country: increased competition.

·        Operating costs - salaries, supplies, and utilities - have continuously gone up.

·        Hospitals stakeholders - patients, their employers, doctors, nurses, - have likewise become more demanding and have raised their expectations from hospitals.

 Few objectives a hospital would like to achieve through change management

·       Inculcate the hotel component in the hospital.

·       Management staff becoming more proactive rather than reactive.

·       Increasing patient satisfaction by reducing waiting times.

·       Reduce costs.

·       Reduce length of stay of patients.

·       Improve quality of services etc.   

Dr. Sugata Pyne

MHA-Hospital Administration

2012-2014 Batch

TISS,Mumbai