Rashmi Lamichhane

 This blogpost is dedicated to all the people who have died from suicide and felt like they were not seen and heard. Your life mattered!

Introduction

The COVID-19 pandemic highlighted how a natural disaster can lead to a significant increase, namely by 25%, in the global prevalence of mental disorders, particularly the global prevalence of anxiety and depression.^[i] Nepal was no exception to this phenomenon. During the time of the lockdown, from 23 March till 6 June 2020, the Nepal Police confirmed 1227 suicide cases amounting to 16.5 suicide cases a day which was higher than the previous year with a total of 5785 suicide cases throughout the year, amounting to 15.8 cases a day.^[ii] It must be emphasized, however, that Nepal was already lacking high-quality mental health services, as well as mental health policies before the COVID-19 pandemic. This blog post examines whether Nepal is fulfilling its obligations under Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR).^[iii]

Legal Basis

In International Human Rights Law Article 12 (1) ICESCR recognizes the right to the “highest attainable standard” of health which includes both physical and mental health.^[iv] The Committee on Economic, Social and Cultural Rights (CESCR) interprets this right as a right to “timely and appropriate health care” as well as to “the underlying determinants of health.”^[v] The underlying determinants that have a crucial impact on mental health are the physical,^[vi] emotional and psychosocial environment.^[vii] Moreover, the Special Rapporteur on the right to health affirms the critical role of “inequitable laws, structures of governance and power, and policies” in shaping the behavior of an individual along with shaping the nature of human relationships.^[viii]

Realization of the Right to Mental Health in Nepal

The right to health, being a broad right, raises the question of how it ought to be realized. According to Articles 2(1) and 12(2) ICESCR, States parties are obliged to progressively realize this right, meaning they need to move “as expeditiously and effectively as possible” towards the full realization of Article 12.^[ix] However, they are obliged “to begin immediately to take steps to fulfil their obligations under the Covenant” and ensure the exercise of this right in a non-discriminatory manner.^[x]

Mental health is still a topic that is not openly discussed and talked about in Nepal, as it remains heavily stigmatized in society.^[xi] However, Nepal has been able to progressively raise more awareness towards mental health and illnesses. This development is also affirmed by “the establishment of a specific mental health desk within the Ministry of Health and Population’s Department of Health Services”, as well as with the listing of mental health care as part of the basic health services in the Public Health Services Act of 2075 (2018) in Nepal.^[xii] Nevertheless, Nepal has no stand-alone mental health policy yet. Currently, the 2020 National Mental Health Strategy and Action Plan, a replacement for the 1996 policy,^[xiii] is in place and has as its guiding principles: “to ensure easy and equal access to high-quality mental health services; integrate mental health services into primary healthcare […].”^[xiv]

In accordance with General Comment 14, which was issued by the CESCR and elaborates on the right to health, there are certain “interrelated and essential features” that are required for the realization of the right to health.^[xv] These features are also known as the “AAAQ” principles, which consist of the categories availability, accessibility -including the dimensions of non-discrimination, physical accessibility, economic accessibility and information accessibility - acceptability and quality.^[xvi] Therefore, States parties are obliged to ensure access to mental health care services and goods including “preventive, curative, rehabilitative care” to fulfil these essential features.^[xvii]

Though the 2020 policy appears to be promising and is in line with the obligations deriving from the ICESCR, the below average health budget in Nepal, namely 7.5% of its gross domestic product (GDP), will not suffice for the realization of the guiding principles of the policy.^[xviii] Furthermore, Nepal falls short in making high quality mental healthcare available and accessible for everyone: it only offers one public hospital dedicated to mental health and 25 in-patient psychiatric facilities with a total of 500 beds for a population of around 29 million.^[xix] In addition to this, there are clearly not enough trained psychiatrists and psychologists for the entire population, given that, by estimation, Nepal counts 144 psychiatrists, three child psychiatrists and thirty psychologists.^[xx] Not only is there a lack of general mental health professionals, there is also a lack of specialists in related fields, such as addiction or child mental health.^[xxi]

Additionally, people in Nepal tend to seek the help of faith healers first when they are dealing with common as well as severe mental health conditions. It should be mentioned, however, that this tendency is improving according to a recent study that focused on “assessing the help seeking behaviors of the community and available health services” in Nepal.^[xxii] Moreover, it must be noted that, globally, the gap between the number of individuals who need treatment at a mental healthcare facility and the individuals who actually receive such a treatment is striking. Nepal is no exception to this phenomenon: According to a study focusing on treatment contact coverage for depressive disorder (DD) and alcohol use disorder (AUD) in Nepal, only 8.1% of participating individuals with DD and 5.1% with AUD received treatment from healthcare providers.^[xxiii] Among the most relevant barriers for the hesitancy to seek professional treatment were economical barriers, concerns about being perceived as “weak” or “crazy” and concerns about how to access the treatment, as there is a lack of awareness of the facilities that offer mental health services.^[xxiv] 

Concluding remarks: the right to mental health in Nepal

To conclude, it cannot be denied that Nepal has improved in ensuring mental healthcare for everyone and raising awareness for mental health.^[xxv] However, Nepal is failing to meet the essential AAAQ standards that are required for the realization of the right to mental health. First of all, there are not enough facilities that offer high quality mental health services in Nepal and therefore not sufficiently available and accessible. Furthermore, the shortage of personnel suggests that the quality of mental health services is not met either. Additionally, this lack of sufficient high quality mental health services and goods coupled with economic barriers can be considered a de facto and de jure breach of the right to mental health.^[xxvi] As Nepal is failing to meet the AAAQ standards, Nepal is consequently failing to progressively realize the right to mental health and thus failing to fulfil its obligations under the Covenant and violating the right to mental health under Article 12 ICESCR.

So, in order for Nepal to comply with its obligations under Article 12 ICESCR, Nepal must start campaigns normalizing talking about mental health, especially in rural areas, and informing about the existing mental health services in Nepal. This should consequently lead to more people seeking mental health treatment instead of reaching out to faith healers or not seeking help at all and in general to a culture of talking about mental health struggles, be it within the local communities or with family and friends. Furthermore, Nepal has to ensure that more students are inclined to be psychiatrists or psychologists, so that the quality of mental health services and goods can improve as well. This could be done by raising more awareness towards the programs related to mental health in universities. Moreover, Nepal should set a higher budget for the health department to guarantee that the right to mental health can be realized progressively.

^[i]  WHO, ‘COVID-19 pandemic triggers 25% increase in prevalence of anxiety and depression worldwide: Wake-up call to all countries to step up mental health services and support’ (2 March 2022) accessed under:  https://www.who.int/news/item/02-03-2022-covid-19-pandemic-triggers-25-increase-in-prevalence-of-anxiety-and-depression-worldwide.

^[ii]  Kritika Poudel and Pramod Subedi, ‘Impact of COVID-19 pandemic on socioeconomic and mental health aspects in Nepal’ (8 December 2020) Volume 66, Issue 8 International Journal of Social Psychiatry, pp. 748-755, accessed under: https://doi.org/10.1177/0020764020942247.

^[iii] International Covenant on Economic, Social and Cultural Rights (adopted 19 December 1966) (entry into force: 3 January 1976) (Trb. 1969 Nr. 99), art. 12 ICESCR. Furthermore, it has to be mentioned that the right to health under other treaties also require the right to mental health: Art. 25 UN Convention on the Rights of Persons with Disabilities (CRPD), Art. 12 Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) and Art. 24 UN Convention on the Rights of the Child (CRC). Nepal is party to all these treaties.

^[iv] See art. 12 (1) ICESCR (n iii).

^[v] UN CESCR General Comment 14: The Right to the Highest Attainable Standard of Health (Art. 12) (11 August 2000) UN doc. E/C.12/2000/4, para. 11.

^[vi]  Ibid. The physical environment includes factors “such as access to safe and potable water and adequate sanitation, an adequate supply of safe food, nutrition and housing, healthy occupational and environmental conditions, and access to health-related education and information, including on sexual and reproductive health.”

^[vii] Human Rights Council, ‘Report of the United Nations High Commissioner for Human Rights, Mental Health and Human Rights’ (31 January 2017) UN doc. A/HRC/34/32, para. 6. The emotional and psychosocial environment include factors such as “violence and abuse, adverse childhood experiences, early childhood development and whether there are supportive and tolerant relationships in the family, the workplace and other settings.”

^[viii]  Human Rights Council, ‘Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Right of everyone to the enjoyment of the highest attainable standard of physical and mental health’ (12 April 2019) UN doc. A/HRC/41/34, para. 5.

^[ix]  UN CESCR, General Comment No. 3: The Nature of the States Parties’ obligations (Art. 2, Para. 1, of the Covenant) (14 December 1990) UN doc. E/1991/23, para. 9. See also UN CESCR, General Comment No. 14 (n iv) para. 30 and Art. 12 ICESCR (n iii).

^[x]  Limburg Principles on the Implementation of the ICESCR (1986) UN doc E/CN4/1987/17, 22. Limburg Principles are a non-binding guidance regarding the implementation of the ICESCR.

^[xi] People believe that mental illness is separate from physical illness as “[t]he mind and the body are considered distinct entities in Nepalese culture.” Therefore, mental illness is viewed more as a “spiritual dysfunction” or “weak mind”. See Yugesh Rai, Deoman Gurung and Kamal Gautam, ‘Insights and Challenges: mental health services in Nepal’ (May 2021) BJPsych International 18 (2): E5 doi: 10.1192/bji.2020.58, accessed under: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8274424/.

^[xii] Nepal, WHO Special Initiative for Mental Health, Situational Assessment, accessed under: https://cdn.who.int/media/docs/default-source/mental-health/special-initiative/who-special-initiative-country-report---nepal---2022.pdf?sfvrs.

^[xiii] Singh R. and Khadka S., ‘Mental Health Law in Nepal’ (7 October 2021) Cambridge University Press, pp. 1-2.

^[xiv]  Nepal, WHO Special Initiative for Mental Health, Situational Assessment, accessed under: https://cdn.who.int/media/docs/default-source/mental-health/special-initiative/who-special-initiative-country-report---nepal---2022.pdf?sfvrs.

^[xv]  UN CESCR, General Comment 14 (n iv) para. 12.

^[xvi]  Ibid.

^[xvii]  Ibid., para. 17.

^[xviii]  Dylan Priday, ‘Addressing Mental Health IN Nepal’ (16 December 2022) The Borgen Project, accessed under: https://borgenproject.org/mental-health-in-nepal/. See also UNICEF, Health Budget: FY 2021/2022 (September 2021) PF4C Budget Brief Updates No. 3, accessed under:   https://www.unicef.org/nepal/media/14426/file/Budget%20Brief%20-%202021-22%20-%20Health.pdf. The health budget of Nepal decreased from 7% to 4% of its GDP throughout the years of 2009/10 to 2017/18 and slightly increased during the COVID-Pandemic up to 7.5%, which is still way below the global average of 10%. Moreover, only 1% of this budget accounts for mental healthcare (therefore see: Singh R. and Khadka S. (n xii) p. 1.

^[xix]   Yugesh Rai, Deoman Gurung and Kamal Gautam (n xi). 

^[xx] Nepal, WHO Special Initiative for Mental Health, Situational Assessment, accessed under: https://cdn.who.int/media/docs/default-source/mental-health/special-initiative/who-special-initiative-country-report---nepal---2022.pdf?sfvrs.

^[xxi] Ibid.

^[xxii] Gupta A. K., Joshi S. et al., ‘Pathways to mental health care in Nepal: a 14-center nationwide study (2021) International Journal of Mental Health System 15:85, accessed under: https://ijmhs.biomedcentral.com/counter/pdf/10.1186/s13033-021-00509-4.pdf. 

^[xxiii]  Luitel N., Jordans M. et al., ‘Treatment gap and barriers for mental health care: A cross-sectional community survey in Nepal’ (17 August 2017) PLOS One 12(8): e0183223, accessed under: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0183223.

^[xxiv] Ibid.

^[xxv] Visit https://jayamentalhealth.org.uk/our-life-changing-projects-2022/ for current projects regarding the improvement of mental health services in specific areas as well as regarding raising awareness for mental health in general.

^[xxvi]  See judgment of Purohit and Moore v Gambia, Communication No 241/2001 (2003).