The RCPsych Article of the Month for April is ‘Systematic evaluation of the QualityRights programme in public mental health facilities in Gujarat, India’ and the blog is written by Authors Soumitra Pathare, Jasmine Kalha.

Mental health care services in low- and middle-income countries are often not available, accessible, affordable, or of good quality that tends to make persons with lived experience vulnerable to denial of their rights. To systematically address this concern, the WHO’s innovative framework of QualityRights was implemented for strengthening mental health systems at scale across nine public mental health facilities, in collaboration with the State of Gujarat from 2014-2016.

QualityRights aims to reorient services from a purely biomedical approach towards a rights and recovery oriented approach. The methodology provides for a participatory and strengths-based approach that focused on organisational culture change where voices of every stakeholder can be included, from policy makers to persons with lived experience.

The core elements of the intervention include:

(i) improvements in the mental health facility environment using existing available resources from facilities and government; (ii) capacity building for health workers, service users and families on human rights and changes in attitudes and practices required to move towards a recovery approach which will enhance autonomy and engage service users in recovery plans; (iii) building peer and family support programmes delivered by non-specialists called Maitri (service user) groups build a peer network of people able to actively support each other and participate in planning service delivery at the intervention services and Saathi (family) groups provide emotional support

and enable members to participate in their relative’s care; and (iv) introducing facility-level policy and mechanisms to govern practices to protect against inhuman, degrading treatment, violence and abuse (including the use of restraints).

The intervention demonstrated that it is possible to apply QualityRights framework to bringing a paradigm shift in the way mental health care is delivered in the context of limited resources in a low-middle income country setting. The evaluation showed increased adherence to UN CRPD principles in mental health care facilities as enlisted in QualityRights Toolkit. The intervention enabled recovery, increased empowerment and satisfaction and reduction in disability in people accessing the services. Professionals reported improved attitudes towards persons with lived experience and coercion as a violation of rights.

One of the unique interventions was the inclusion of peer support in a formal mental health system. The impact of this policy reform enables access to peer support, financially supported by the State. Janki Patel, a peer support volunteer (PSV) said “the training helped me understand more about the concept of recovery. Working as a PSV, I feel empowered that I can help others too. I feel an increased amount of confidence within myself”. The team is working towards developing a scalable model for peer support at present.

The intervention could reform the landscape of mental health systems to one that foregrounds people’s will and preferences, increased democratic decision-making power from all stakeholders. The methodology provides a pathway for a global reform that moves away from a biomedical approach that focuses solely on symptomatic recovery, and instead, allows for people to lead healthy, fulfilling lives despite their symptoms.

Link to Film about QualityRights Gujarat:

Why I chose this article:

‘Scrutiny of the World Health Organization (WHO) over the past year has been (dare I say) unprecedented and was intensified by the controversial in–out–in US policy dance. Research demonstrating the positive impact and value of WHO initiatives is therefore timely. A pragmatic implementation trial published in the British Journal of Psychiatry this month by Pathare et al (pp. 196–203) provides just that. Based in Gujarat, India, it describes the roll out and evaluation of the WHO ‘QualityRights’ initiative – a participatory framework designed to promote human rights within mental health services. Where QualityRights was implemented over a year, people using the services were more likely to report an increase (albeit small) in empowerment and satisfaction compared with standard services.’

Dr Kate Adlington, Highlights Editor, BJPsych