Introductory commentary on WHO QualityRights

Article Type: Commentary From: Journal of Public Mental Health, Volume 12, Issue 4

© World Health Organization 2013

On 26 April 2013, a blaze engulfed a psychiatric hospital in a village near Moscow, killing 38 people (BBC News, 2013a; The New York Times, 2013). In May of the same year, patients rioted against conditions and escaped from Kenya's Mathari Mental Hospital, known for its human rights abuses (BBC News, 2013b; Al Jazeera, 2013). In the same month, the Victorian Mental Illness Awareness Council (2013) reported widespread sexual abuse of women in psychiatric facilities (ABC News, 2013). These news stories, spanning a period of only eight weeks, provide a snapshot of the dire situation faced by people with mental disabilities in facilities across the world. These stories are startling, not only because they are horrific, but also because they are banal. These human tragedies are not isolated or unusual. They are not just occurring in low-resource settings. The reality is that across the world, people with mental disabilities are exposed to harm and danger, in the very facilities that should be providing them with care, support and protection.

Indeed human rights violations and poor quality care are an everyday occurrence in mental health facilities in many countries. The lack of resources devoted to mental health, a "dehumanization" of people with mental disabilities and the poor level of knowledge and understanding about human rights means that facilities are associated with poor treatment outcomes and a wide range of abuses. Many people are exposed to physical, sexual and emotional abuse. A systematic and comprehensive review and meta-analysis undertaken in 2012 shows that as many as one in four people report experiencing violence in a one-year period(Hughes et al., 2012).

Unhygienic and inhuman living conditions are common, as are harmful and degrading treatment practices. People are not provided with adequate mental health treatment and also lack access to physical health care services. In other cases people are neglected altogether and receive no treatment or care at all. People are arbitrarily locked up in institutions against their will sometimes for years at a time. In fact almost 25 per cent of people admitted to institutions across the world remain in these facilities longer than a year after admission, due to the lack of support services in the community (World Health Organization, 2011). Many are held in cell-like rooms and put in seclusion and restraint for long periods of time. Informed consent to treatment is systematically ignored in many facilities, and basic rights such as the right to confidentiality, to access information(including clinical records), to privacy, to communication, are frequently violated. Yet despite these abuses, globally 67 per cent of mental health spending is directed towards mental hospitals and 63 per cent of psychiatric beds are located in these institutions (World Health Organization, 2011). Violations are not restricted to inpatient and residential facilities, however; many people seeking care from outpatient and community care services are disempowered and also experience extensive restrictions to their basic human rights.

The WHO QualityRights Project: Act Unite And Empower For Mental Health aims to change this situation. The project, which was launched in June of 2012, has four major objectives:

* improve quality and human rights in both inpatient and outpatient facilities;

* build capacity among service users, families and health workers to understand and promote rights and recovery;

* establish a strong movement of persons with mental disabilities to provide mutual support, conduct advocacy and contribute to decision-making processes; and

* reform national legislation and policy in line with international human rights standards and best practice.

Countries undertaking QualityRights establish visiting committees made up of persons with mental disabilities, families, mental health professionals and legal and human rights experts. These teams receive training on how to assess and report on quality and human rights conditions in a full range of facilities including psychiatric hospitals, psychiatric wards in general hospitals but also outpatient services such as community mental health centres, primary care clinics and day-care centres among others. Following the assessment, the visiting committee works collaboratively with mental health service users, family and staff to put in place improvement plans for facilities. This is also an opportunity to raise awareness and educate everyone involved on human rights issues. Technical and administrative support is also provided to people with mental disabilities from the facilities and community on how to set up self-advocacy organizations, in order to: provide mutual support, information and training on mental health and human rights to other service-users, their families and the community; undertake advocacy and campaigning; and participate in decision-making processes. In order to produce sustainable change, WHO also works with countries to reform national policies and laws in line with best practice and international human rights standards, in particular the CRPD.

An important element of the project is the WHO tool kit to assess and improve quality and human rights in mental health and social care facilities (World Health Organization, 2012). Using the CRPD as its framework, the tool kit establishes key standards that need to be met in both inpatient and outpatient facilities. It also provides guidance on how to set up a multi-disciplinary visiting body and on how to conduct a comprehensive assessment of facilities as well as report and make appropriate recommendations based on the assessment.

WHO QualityRights Tool Kit has a number of unique features. It can be applied in low-, middle- and high-income countries and in both inpatient and outpatient facilities. It promotes a recovery approach to mental health care, moving beyond a traditional medical model based on medication to manage symptoms, to an approach that encompasses the goals and aspirations of individuals and provides support in accessing employment and educational opportunities as well as housing and social services. It also promotes a participatory approach. Service users, families and health professionals not only conduct the assessment but work together to put in place a concrete plan of action to improve conditions in facilities. Up until now it has been common practice for only health professionals to be involved in quality assessments. Another important feature is that the tool kit allows for a comparison between mental health and general health care services to get a better understanding of the degree of parity between these two areas of health.

The tool kit can be used by a wide variety of State and non-State actors including NGOs, Ministries of Health, National Human Rights Institutions, National Health/Mental Health Commissions, health service accreditation bodies and other bodies.

WHO QualityRights has already achieved results in countries. In Somaliland, an assessment of Hargesia Hospital enabled the identification of specific gaps in the delivery of services. Subsequently, measures have been put in place to address poor standards of care and living conditions. Furthermore many long-term service users have been released from the hospital and some have found employment, additional health professionals have been appointed, hygiene standards have improved and the practice of chaining service users has ceased O’Hara (2012). Assessment in a number of inpatient and outpatient facilities in Asturias, an autonomous region of Spain, led to the development of a mental health strategic plan to improve services. A mental health commission with eight representatives (including service users, family members, human rights experts and a psychiatrist) was also established to advise the Ministry of Health. In addition, a Bill of Rights for persons with mental disabilities has been developed. In Palestine, Greece and Brazil, assessment of individual facilities have also identified clear service gaps in care and human rights conditions, highlighting specific areas for service development.

The papers in this special edition of the Journal of Public Mental Health underscore some of the massive challenges faced by people with mental disabilities in countries around the world. They also highlight that there is reason for optimism that important efforts are underway in countries around the world to end violations and promote human rights and quality care, in line with the goals and objectives of the WHO QualityRights Project.

Dr Michelle Karen Funk and Natalie Jane Drew World Health Organization, Geneva, Switzerland

References

ABC News (2013), "Calls for sexual abuse investigation in Australian psychiatric facilities", ABC News, 14 May, available at: http://www.abc.net.au/worldtoday/content/2013/s3758577.htm (accessed 5 November 2013)

Al Jazeera (2013), "Kenya clinic riot spotlights mental health", Al Jazeera, 17 May, available at: http://www.aljazeera.com/indepth/features/2013/05/201351711252816185.html (accessed 5 November 2013).

BBC News (2013a), "Dozens feared dead in Russian psychiatric hospital fire", BBC News, 26 April, available at: http://www.bbc.co.uk/news/world-europe-22305664 (accessed 5 November 2013).

BBC News (2013b), "Kenyan patients escape from Nairobi's Mathari Hospital", BBC News, 13 May, available at: http://www.bbc.co.uk/news/world-africa-22509446 (accessed 5 November 2013).

Hughes, K., Bellis, M.A., Jones, L., Wood, S., Bates, G., Eckley, L., McCoy, E., Mikton, C., Shakespeare, T. and Officer, A. (2012), "Prevalence and risk of violence against adults with disabilities: a systematic review and meta-analysis of observational studies", The Lancet, Vol. 379 No. 9826, pp. 1621-9

(The) New York Times (2013), "Fire in Russian Psychiatric Hospital That Killed 38 Stirs Anger Over State's Neglect", The New York Times, 26 April, available at: http://www.nytimes.com/2013/04/27/world/europe/fire-at-russian-psychiatric-hospital.html(accessed 5 November 2013).

O'Hara, M. (2012), "Fighting for their rights", Mental Health Today, September/October, p. 8

Victorian Mental Illness Awareness Council (2013), "Zero tolerance for sexual assault: a safe admission for women", Victorian Mental Illness Awareness Council (VMIAC), available at: http://www.vmiac.org.au/pub/zero_tolerance_for_sexual_assault.pdf

World Health Organization (2011), "WHO Mental Health Atlas: 2011", available at: http://www.who.int/mental_health/publications/mental_health_atlas_2011/en/ (accessed 5 November 2013).

World Health Organization (2012), "WHO QualityRights Tool Kit to assess and improve quality and human rights in mental health and social care facilities", World Health Organization, Geneva, available at: http://apps.who.int/iris/bitstream/10665/70927/3/9789241548410_eng.pdf (accessed 5 November 2013).