Mental health–related structural stigma and discrimination in health and social policies in Nepal: A scoping review and synthesis

Aims National policies can be used to reveal structural stigma and discrimination in relation to mental health. This review assesses how structural stigma and discrimination are manifested in the policies and legislations of Government of Nepal. Methods Scoping review methodology was followed to review policy documents (acts of parliament, legislation, policies, strategies, guidelines and official directives) drafted or amended after 2010. Results Eighty-nine policies were identified related to health, social welfare, development and regulations which were relevant to people with psychosocial and mental disabilities or have addressed the mental health agendas. Several critical policy failings and gaps are revealed, such as the use of stigmatizing language (e.g., ‘insane’ or ‘lunatic’), inconsistencies within and between policies, deviation from international protocols defining legal capacity and consent, lack of inclusion of the mental health agenda in larger development policies and lack of cost-effective interventions and identification of financing mechanisms. Provisions for people living with mental health conditions included adequate standard of living; attaining standard mental health; the right to exercise legal capacity, liberty and security; freedom from torture or discrimination; and right to live independently. However, other policies contradicted these rights, such as prohibiting marriage, candidacy for and retention of positions of authority and vulnerability to imprisonment. Conclusion Mental health–related structural stigma and discrimination in Nepal can be identified through the use of discriminator language and provisions in the policies. The structural stigma and discrimination may be addressed through revision of the discriminating policies, integrating the mental health agenda into larger national and provincial policies, and streamlining policies to comply with national and international protocols.


Introduction
For people with lived experience of mental health conditions (PWLE), stigma can result in adverse repercussions in their lives, families and society.Stigma can be defined as problems of knowledge, attitude and behaviours that arise due to perceived biases against PWLE (Thornicroft et al., 2007).Stigma has been highlighted as a key barrier to accessing treatment (Schomerus et al., 2019).It also infringes on the basic human rights of PWLE, thus exacerbating marginalization and exclusion (Thornicroft et al., 2022).
Two decades ago, it was noted that most stigma research focused on frameworks and pathways at the personal level looking into the internalized and interpersonal interactions, while ignoring the macro-level issues underlying stigma (Link and Phelan, 2001).Although much is known about individual experiences of stigma, frameworks that ignore the multi-level mechanisms of stigma limit the understanding of what factors influence and mediate stigma processes (Stangl et al., 2019).Therefore, more studies and actions are needed to consider the macro-level factors and mechanisms of stigma -also called 'structural stigma' (Hatzenbuehler and Link, 2014;Thornicroft et al., 2022).
Structural stigma is the 'societal-level conditions, cultural norms, and institutional practices that constrain the opportunities, resources, and wellbeing for stigmatized populations' (Hatzenbuehler and Link, 2014).It refers to policies and practices causing intentional or unintentional disadvantages for the stigmatized population, thus creating and perpetuating social inequities for PWLE (Knaak et al., 2020).Empirical research on structural forms of stigma and discrimination comes from social and political sciences that investigates its negative outcomes on sexual and racial minorities.However, there is a dearth in understanding structural stigma in relation to mental health conditions (Hatzenbuehler et al., 2010).Some studies have tried to address this gap by documenting structural discrimination in legal provisions such as prohibition in marriage and voting, violation of property rights and involuntary admissions that have violated the rights of persons with psychosocial and mental disabilities (Bhugra et al., 2016;Conley and Baum, 2023).
Since the 1990s, Nepal has seen changes in the mental health policy landscape.Amidst political and environmental disasters, the mental health sector has undergone reforms (Singh and Khadka, 2022).The first national mental health policy was formed in 1996; however, its status of implementation was questionable.The Bhutanese refugee situation and the Maoist conflict highlighted the need for psychosocial and mental healthcare in Nepal.After the earthquake in 2015 and after the prioritization of mental health in United Nation's Sustainable Development Goals, the mental health agenda gained momentum in Nepal with its inclusion in the nation's development plan and designation of a division in the Department of Health Services as a focal unit to oversee mental health programmes.This led to the drafting of a national community mental healthcare package that was brought into implementation in 2017 (Government of Nepal, 2017b).
After the inclusion of mental health into the National Health Policy in 2019, a National Mental Health Strategy and Action Plan was developed in 2020, which remains the only policy document that solely addresses mental health (Government of Nepal, 2021a).Despite these reforms, the mental health sector faces numerous challenges.At least 9 of 10 people with mental health conditions in Nepal do not access mental health treatment, and stigma has been identified as the leading barrier in access to care (Luitel et al., 2019(Luitel et al., , 2017)).Stigma is reflected in the structures of Nepali society such as the policy environment and these structures, along with cultural norms of 'what matters most' such as productivity, prestige and acceptance, further driving stigma in Nepal (Gurung et al., 2022).Hence, the aim of this review is to understand the provisions for PWLE in Nepal's policies and legislations and assess how structural stigma and discrimination are manifested within these policies.

Methods
We conducted a scoping review using the Arksey and O'Malley scoping review method that suggests defining the question, identifying, selecting mapping data, summarizing, synthesizing and reporting findings (Arksey and O'Malley, 2005).We reviewed National and Provincial policies using the following guiding questions: 1) How are mental health issues and persons with lived experience of mental health conditions and psychosocial disabilities (PWLEs) labelled and defined in these policies?2) What are the provisions that promote the rights of PWLEs?Table 1.Inclusion criteria for screening policy documents Laws, legislations, acts, policies, guidelines, directives, rules, regulations, programmes, strategies, plans, orders/bills drafted or passed by institutions and bodies under the Government of Nepal which -contain any text related to mental or psychosocial or psychological health/disability/services/programmes -are available in English and/or Nepali -were drafted or amended after 01 January 2010 to 31 April 2022 [The year after 2010 was chosen (for drafting and amendment) because due to the then political scenario of Nepal (such as drafting of interim constitutions and transition to federal system of government) most of the relevant policies that were being implemented at the time had gone through amendment].
3) What are the notable gaps in the policies that restrict the basic human rights of PWLEs?

Search and screening strategy
We conducted systematic searches in three government websites: (i) Ministry of Health and Population (MoHP) (https://mohp.gov.np/en); (ii) Ministry of Women, Children, and Senior Citizens (MoWCSC) (https://mowcsc.gov.np/en); and (iii) Nepal Law Commission (https://lawcommission.gov.np/en/).Additionally, DG emailed 10 stakeholders and policymakers working in the field of mental health to identify and share relevant policy documents.Each document available in English was screened in two steps.First, documents were screened for their mention of terms related to mental health, discrimination, psychosocial/psychological and disability (using the terms 'mental' , 'discrim*' , 'psych*'and 'disab*').Second, they were screened to assess if they met the inclusion criteria (see text box 1 for the inclusion criteria).The documents available only in Nepali were assessed by reviewers fluent in Nepali to screen if they met the inclusion criteria.Full review was conducted for Nepali-only documents by reviewers as using search terms in Nepali fonts was not feasible.Document search and screening were carried out from February to December 2021; documents collected via emails from stakeholders were screened until April 2022 (Table 1).

Extraction and synthesis
Three reviewers (DG, NCG and KB) extracted information from the documents that met inclusion criteria into a data extraction sheet that recorded their type, year of information, year of final amendment, inclusion of key terms and texts related to the key terms within the document.As our definition of the policy included a range of documents from laws to directives issued by the government and covered not just mental health but also general health, social welfare and regulatory policies, following just one policy analysis framework was not feasible.Therefore, we developed a separate framework adapted from indicators recommended by WHO in the mental health legislation, policy and plan checklists and in the WHO QualityRights toolkit (World Health Organization, 2012).
The adapted framework consisted of the following themes that were used to code and synthesize the extracted text: (i) language and definitions; (ii) expansion and contraction of rights and liberties; (iii) integration and consistency with the national policy and legislative environment; (iv) coordination and inter-sectoral collaborations; and (v) financing.Most of the policy documents were reviewed in their English-translated format made available by the Law Commission website.However, for the language and definitions, both the official Nepali version of the documents along with their English-translated documents were reviewed to identify stigma terminology.Any questions and/or disparities were discussed among the reviewers to form a consensus and reduce subjectivity.After data extraction and mapping, DG carried out a synthesis of the results and shared with the review team for inputs.

Policy selection
There were 475 policies listed in the Law Commission website, 140 in the MoHP and 88 in the MoWCSC website (Fig. 1).In addition, 29 potentially relevant documents were sourced via key stakeholders.After removing 23 duplicates, 709 policy documents were included for screening.We removed 594 policy documents after initial screening because they had not been drafted or updated since 2010 or because those documents did not include any terms related to mental or psychosocial or psychological health/disability/services/programmes.Documents were removed when a contemporary policy overriding the older one was identified.The remaining 115 policy documents were reviewed in full text, after which 26 were removed for not having provisions that were directly related to psychosocial and mental health/disabilities or affected the people with psychosocial and mental health conditions.A total of 89 policy documents were included in the study for data extraction and synthesis (Table 2).

Language and definitions
We identified 23 of 89 policy documents with stigmatizing terms.The original Nepali terms and the English translations made available in the Law Commission website are shown in Table 3.Since 2015, policies were more likely to use neutral terminology such as 'persons with psychosocial and mental disabilities' .
We found no policy documents that formally provided definitions of mental health conditions, mental disorders or psychosocial problems.This could be because there is no legislation specific to mental health.The commonly used terminology that relates to persons with mental health conditions included in most of the social and civil policy documents is 'of unsound mind' (Nepali: hosh thegan ma naraheko).This is a legal terminology that is defined in the National Penal (Code) Act, 2017 as '… the condition of being incapable due to physical and mental ill health, of knowing the act done by oneself in general understanding and consequences thereof ' (Government of Nepal, 2017e).Other stigmatizing terms such as 'insane' , 'mentally unsound person' and 'lunatic' were used in some of the civil policies.
Most policies mentioned health in general without distinguishing between mental health and physical health.The Public Health Service Act, 2017 (Government of Nepal, 2018f) mentions health services related to ayurveda, allopathy, homeopathy and other natural treatments but does not mention psychosocial therapies and counselling services.Policy documents have not distinguished different types of mental disorders, and rather use overarching terms such as mental health/mental disorders, and mental disability.
Some policy documents included psychosocial and mental disabilities in their definitions of disability.The closest legislative document that relates to mental health is the Act Relating to the Rights of Persons with Disabilities (will be referred to as the Disability Act henceforth) (Government of Nepal, 2017a).The Disability Act has further defined disability as -'a person who has long-term physical, mental, intellectual, or sensory disability, or functional impairments, or existing barriers that may hinder his or her full and effective participation in the social life on an equal basis with others' .However, the definition and difference between 'persons with psychosocial' and 'persons with mental' disabilities are missing here too.The Disability Act in the classification of disabilities has further defined mental or psycho-social disability as 'the inability to behave in accordance with age and situation Mental health conditions as afflictions • suffering from a mental illness/mental unsoundness • mental disease • The Social Security Act, 2018 • National Youth Policy, 2010 • National Operating Guide for Leprosy Program, 2018 Terminology implying incompetence • National Civil Code, 2017 • The Social Security Act, 2018 and delay in intellectual learning due to problems in performing intellectual activities like problems arising in the brain and mental parts and awareness, orientation, alertness, memory, language, and calculation' .This definition, however, focuses on developmental and intellectual disability but fails to capture the range of other psychosocial and mental disabilities.

Expansion or contraction of rights and liberties
The expansion or contraction of rights and liberties of PWLEs in the policy documents is summarized in five themes based on the WHO QualityRights Tool Kit: (i) right to an adequate standard of living; (ii) right to the enjoyment of highest attainable standard of physical and mental health; (iii) right to exercise legal capacity and right to personal liberty and security; (iv) freedom from torture or cruel, inhuman, or degrading treatment or punishment and from exploitation, violence, discrimination and abuse; and (v) right to live independently and be included in the community.

Right to adequate standard of living
This sub-theme includes the right to privacy, housing and social security for PWLEs addressed in various policy documents.
The Right to Housing Act does not directly address protection of housing for PWLEs.However, it notes that 'No citizen shall be made deprived of, or discriminated from, the facility of housing on the ground of origin, religion, class, caste, ethnicity, gender, physical condition, disability, health condition, marital status, pregnancy, economic condition, language or region, ideology or any other such grounds' (Government of Nepal, 2018h).It has special consideration for eviction due to public purposes for persons with disability, helpless and elderly citizens, although provisions for homelessness due to mental health conditions are not discussed.The Disability Act does mention housing programmes for persons with psychosocial disabilities who have been disregarded by their family members (Government of Nepal, 2017a).It does not outline who, where and how they will be housed or rehabilitated.
The Social Security Act has adopted the definition of disability to include mental and intellectual disability and has defined 'incapacitated and helpless' as those who are incapacitated to become economically productive due to physical or mental conditions and have no family members capable of taking care of them (Government of Nepal, 2018i).The act mentions that these citizens certified by doctors as suffering from (amongst others) 'mental retardation' and 'mental unsoundness' are entitled to social security which includes allowances specified by the government.The Privacy Act has provision for privacy of information regarding physical and mental health conditions of each person as inviolable except in matters of consent of the concerned person, in which case such information can be disclosed (Government of Nepal, 2018e).

Right to enjoyment of highest attainable standard of physical and mental health
This sub-theme encapsulates provisions on the availability of treatment, skilled staff, service user-driven treatment and rehabilitation, availability of medication, adequate services available for general and reproductive health, and various interventions highlighted in the policy documents.
The constitution of Nepal states that all citizens have the right to free basic health service from the state (Government of Nepal, 2015), and the Public Health Service Act includes services relating to 'mental disease' (Government of Nepal, 2018f).Most policy documents from the MoWCSC highlight psychosocial and psychological interventions for populations with special needs such as survivors of violence, crime, human trafficking and natural disasters.This includes coverage of fees for psychosocial consultation, psychological evaluations, hospital treatments, psychological treatments and psychotherapies.Psychosocial counselling provision was established for those put in shelter during the COVID-19 pandemic (Government of Nepal, 2020a).
Several documents from the MoHP highlight communitybased mental health interventions.These include free basic health services for priority mental health conditions (depression, psychoses, alcohol use disorder [AUD], conversion disorder, and epilepsy), and provision of 11 free psychotropic medications to be prescribed by trained health workers.To implement this, strategies and operations guidelines have provisioned for the World Health Organization's mental health Gap Action Program adapted training for primary care workers (also termed Module 2 training on mental health) (World Health Organization, 2008).Psychosocial management is highlighted for depression and AUD (Ministry of Health & Population, 2021).Arrangements for specialized psychiatric services have been expanded beyond tertiary psychiatric facilities to include general hospitals and teaching hospitals across the country (Government of Nepal, 2021a).
Indicators in the National Mental Health Strategy and Action Plan and the Multi sectoral Action Plan for Prevention and Control of Non-Communicable Disease (referred to as NCD strategy and action plan henceforth) focused on increased service coverage (e.g., proportion of people using services, number of municipalities implementing community mental health programmes and number of health workers trained) (Government of Nepal, 2021b).However, assessment of quality of services and indicators related to it was missing from the strategies.Table 4 shows interventions that have been highlighted in the policies among key areas and populations.

Right to exercise legal capacity and right to personal liberty and security
The sub-theme includes safeguarding PWLEs against detention and treatment without consent, and support to exercise their legal capacity.Here legal capacity is defined as the capacity to have the rights, to understand and exercise the rights (Bantekas et al., 2018).
The Impeachment Act defines 'incompetence' as the inability to discharge his/her duties due to physical or mental reasons and so not having legal capacity (Government of Nepal, 2002a).Incompetence is determined by a medical board consisting of three concerning specialists who carry out a medical examination.The National Civil Code Act describes a person with competency as any person who attains 18 years except in cases (amongst others) of those who are 'of unsoundness of mind' , i.e., being incapable due to physical and mental ill health of knowing the act done by oneself and its consequences (Government of Nepal, 2017d).Incompetent persons do not bear any legal obligation, and the exercising of their right can be done only with the consent of the guardian/curator or through the guardian/curator.The act mentions that determination of competency is done by the court without providing any detail on how the determination is made.This discrepancy or lack of clarity in determining incompetence within policies makes the implementation of such policies open to situational and contextual factors thus subjecting it to more discrimination.The National Civil Code Act states that no discrimination shall be made in the application of general law on the grounds of (amongst others) physical condition but does not mention mental health conditions (Government of Nepal, 2017d).The Act mentions that consent given by a person of 'unsound mind' due to mental illness if unable to understand the characteristic fault and consequence of the consent will not be considered as consent.This provision on consent is reflected in numerous policy documents: the Public Debt Act (Government of Nepal, 2002b) mentions that if the owners of the bond are 'insane' , their mother/father/husband/wife may be assigned the protector.Payment of principal and interest of a bond of an 'insane' person is done to the guardian and the payment can be made to the person themselves if they submit a certificate from a medical board mentioning details of their wellness.The Public Health Service Act too mentions the provision of health services without informed consent if the service recipient is not in a condition to give consent (Government of Nepal, 2018f).No form of assisted decision-making was mentioned in any of the documents.
Freedom from torture or cruel, inhuman or degrading treatment or punishment, and from exploitation, violence, discrimination and abuse This sub-theme includes provisions in policy documents relating to the right to be free from all forms of abuse and neglect, free from forced treatments and surgeries or Electro Convulsive Therapy (ECT), not subjected to experimentations without consent, and safeguards to prevent torture, cruel treatments and abuse.
The Constitution of Nepal provisions citizens with disabilities to have the right to live with dignity and honour and have equal access to public services and facilities (Government of Nepal, 2015).The National Penal Code Act mentions if the offence was committed against (among others) '… a person being of unsound mind by reason of physical or mental illness or a person incapable of defending himself or herself because of disability …' then it is aggravating the gravity of offence (Government of Nepal, 2017e).The gravity of offence is reduced if the offender has diminished capacity because of physical or mental disability.In the Army Act, accused personnel unable to defend themselves due to 'mental insanity' during the trial by the court martial may be held in a mental hospital or in custody or in any appropriate safe place (Government of Nepal, 2006).They can be released following recommendation of the chief of the mental hospital or prison '…stating that the person might not be harmful to him/herself or anyone else after release' .
The Police Act states that one of the duties of police employees is to '… take charge of lunatics and persons who are dangerously intoxicated and cannot look after themselves' (Government of Nepal, 1955).Similarly, the Prisons Act has provision for arrangements to keep detainees or prisoners who are 'insane and half minded' separated and kept in different parts as far as possible (Government of Nepal, 1963b).These provisions are in contrast with the Disability Act that states that any person with psychosocial and mental disability shall not be detained in the name of treatment or protection (Government of Nepal, 2017a).There was a notable absence of any policies that discussed safeguards for forced treatments and abuses at the health facilities for persons with mental health conditions.Several policies had provisions safeguarding persons with mental health conditions from discrimination.The Public Health Service Act prevents discrimination in treatment because of disability (Government of Nepal, 2018f), and the Crime Victim Protection Act (Government of Nepal, 2018a) prevents discrimination in the justice process on the grounds of physical and mental disability.However, the Right to Employment Act protects against discrimination based on caste or ethnicity, but no health conditions or disability are mentioned (Government of Nepal, 2018g).Some legal documents disqualified or restricted persons with mental health conditions from positions or services (see Table 5).

Right to live independently and be included in the community
This sub-theme captures policies that support accessing financial resources to live in the community; access to education and employment; right to participate in political and public life; right to participate in social, cultural, religious and leisure activities; and fulfilling social and personal lives.
Policies had specific provisions for persons with disabilities (including psychosocial and mental disabilities) relating to participation in sports, rehabilitation and livelihood programmes and arrangement of sports competitions to ensure enjoyment of leisure and livelihood activities (Government of Nepal, 2010a, 1992, 2010b).However, the National Civil Code Act states marriage cannot take place if the person has leprosy, incurable severe diseases, hearing and visual disability, HIV or is of 'unsound mind' (Government of Nepal, 2017d).The Local Level Election Act restricts persons of 'unsound mind' from participating in elections as a candidate (Government of Nepal, 2017c).
The Disability Act has provisions for people with mental health and psychosocial disabilities with entitlements based on severity or socio-economic conditions (Government of Nepal, 2017a).This includes monthly cash allowance; free healthcare and assistive products; education allowance; concession on fees for public transportation; or tax exemption on income, housing, or vehicles.

Integration and consistency with national policy and the legislative environment
In the absence of a national mental health act, we reviewed other health and social policies to understand the extent of inclusion of the mental health agenda and provisions that are applicable to persons with mental health conditions.
All citizens have the right to free basic health services from the State according to the Constitution (Government of Nepal, 2015).The Public Health Service Act has focused on the inclusion of mental health into basic health services (Government of Nepal, 2018f).The Standard Treatment Protocol for Basic Health Services Package includes pharmacological and psychosocial interventions to be provided by primary health facilities (Ministry of Health & Population, 2021).The National Health Policy addresses mental health as a condition of concern and ensures access to mental health and psychosocial services from local health facilities by promoting knowledge and skills transfer in the primary hospitals (Government of Nepal, 2019a).
During the review period, two of the seven provinces (Gandaki and Karnali) passed their own provincial health policies.The Gandaki Province Health Policy has mentioned outpatient and inpatient services for mental illness in district hospitals; programmes to control drugs and alcohol use; prevention, promotion, diagnosis and treatment of mental illnesses in urban health clinics; and the expansion of specialist services for mental illness (Government of Nepal, 2021e).However, the policy does not specify a community mental healthcare package or the provision of mental health services below the district level.The Karnali Province Health Policy focuses on the expansion of mental health services at all levels with specialist health camps to be conducted periodically in rural areas.It addresses the establishment and management of rehabilitation centres for short-term management of (among others) PWLEs who are helpless (Government of Nepal, 2019d).It acknowledges the role of the provincial government to provide quality and cost-effective services to PWLEs.
The National Health Insurance Act has included the coverage for selective mental health conditions (conversion disorder, severe depression, bipolar disorder, epilepsy and schizophrenia) (Government of Nepal, 2018c).However, the benefit packages only cover medical management covering the cost of the psychotropic medicines for these conditions.Mental health indicators are included in the multi-sectoral action plan for NCDs such as a 10% reduction in harmful alcohol use, and an increase in service coverage by 25% (specifically for psychosis and depression) (Government of Nepal, 2021b).Similarly, policies of other health conditions such as leprosy, HIV and AIDS have included provisions for psychosocial counselling and psychiatric services (Government of Nepal, 2018d, 2011, 2014).This shows that mental health is being integrated to some extent into these broader health policies.
Employment and housing policies do not address mental health conditions.Other policies related to children, domestic violence, survivors of human trafficking and social security have provisions specifically for persons with disability.They have added provisions for counselling or therapies for their respective beneficiaries.The Disability Act has secured fundamental rights of persons with disabilities with an additional clause specific to mental health conditions that include treatment at the local community of their choice, rehabilitation and treatment of persons with psychosocial disabilities who have been abandoned by their families, and not to keep such persons in prison (Government of Nepal, 2017a).
Inclusion of mental health in the development agenda and plans were present but scarce.The National Planning Commission (NPC) which produces the 5-year national plan in its 15th Plan and the National Health Sector Strategy implementation plan have identified mental health as a major problem in health and nutrition, and have mentioned plans for expansion of access to mental health services at all levels and systematic development of alternative medicines including psychological counselling along with yoga, meditation and Ayurveda (Government of Nepal, 2020b, 2016).

Coordination and inter-sectoral collaborations
A dedicated governance mechanism to look into mental health at the federal, provincial and municipal levels has been proposed in the national mental health strategy and action plan (Government of Nepal, 2016).However, this is not reflected in the provinciallevel health policies that were included in this review.The National Mental Health Strategy and Action Plan 2020 identifies federal, provincial or local government as responsible and coordinating bodies for all the major activities and has highlighted multilateral and multisectoral coordination and collaboration with the government, non-governmental and private sectors for mental health services (Government of Nepal, 2021a).However, specific action plans for these collaborations are missing.There is a specific strategy for the formation of mental health self-help groups for necessary discussion and decision-making on health treatment and rehabilitation needs.However, there is no mention of any specific action plan on who should form these groups, how they will be formed or collaboration with advocacy groups and service user or caregiver organizations for the implementation of the major activities.
Alternatively, the NCD action plan and strategy have included some strategies for mental health and have delineated clear action plans, target dates and agencies responsible (Government of Nepal, 2021b).For example, for the reduction of harmful use of alcohol, the first action plan is the revision of the alcohol control policy and a bill that is targeted to be completed by 2022 by the MoHP in partnership with the Ministry of Home Affairs (MoHA) and the Ministry of Law, Justice and Parliamentary Affairs.

Financing
The policy documents included in the review did not clearly specify the sources and mechanisms of funding required to finance the implementation of mental health programmes.The Public Health Service Act has mentioned that the financial burden of basic health services (that includes basic mental health) lies on the government (Government of Nepal, 2018f).However, the National Mental Health Strategy and Action Plan has specified action plans that go beyond basic health services.Although the National Health Insurance Act has provisioned additional medications and clinical services not covered by the basic health services, the action plans and interventions do not mention evidence-based financing or cost-effectiveness analysis of prevention, promotion and psychosocial services (Government of Nepal, 2018c).
The operational guidelines for province and local health programmes have detailed activities and budget distribution by the government for various health programmes annually (Government of Nepal, 2019c, 2021c).The guidelines included in the review show ad hoc allocation of a budget with large variations from one year to another for mental health-related programmes.Since 2018, programmes in mental health and its financing were included mainly under the Epidemiology and Disease Control Division, and the activities focused on training of health workers under the community mental healthcare package.Funding for the training of health workers was allocated every year since 2018, although the amount of budget varied.Another programme that received funding for multiple years was the mental health programme for prisoners.Awareness programmes for school health nurses on adolescent mental health and awareness-raising programmes started to be funded in 2018-2019; however, those were not continued in the following year.However, mental health training for school nurses was planned and budgeted for 2021-2022 but not followed up in 2022-2023.A similar case was seen for the purchase of psychotropic medications in each province -which was budgeted only in 2021-2022 but not in the previous or following years.

Discussion
We reviewed 89 public policies, strategies, legislations and guidelines endorsed by the Government of Nepal to assess and understand how structural stigma and discrimination are manifested in these documents.The review identified few positive changes in policies.First, the inclusion of the mental health agenda has been increasing over the years -especially in post-2015 policies.This momentum can be attributed to the heightened focus on psychosocial and mental health field in the aftermath of earthquake, aligning with the 'building back better' concept (Chase et al., 2018).Furthermore, mental health and psychosocial wellbeing are not only included in health policies but are increasingly addressed in social welfare policies, such as those pertaining to children, senior citizens, gender-based violence or trafficking.
Second, compared to the archaic policies (not included in the review), there were notable changes in the language and words used in the recent policies.Words such as baulaahaa/paagal (mad/insane) were commonly used to indicate persons with mental health conditions in major policies such as previous Muluki Ain, 2020 (civil code, 1963) with discriminatory provisions such as chaining and imprisonment of people with mental health conditions until they become 'normal' after treatment (Government of Nepal, 1963a).Such provisions no longer exist in current policies, and in many policies, stigmatizing terms such as lunatic or insane have been replaced by legal terminology such as 'of unsound mind' .
Third, increased attention is given to integrating mental health into primary healthcare and basic health services.This aligns with WHO recommendations for increased coverage and a reduced treatment gap in mental health (World Health Organization, 2008).The NPC periodic plans demonstrate evolving priorities for mental health.The 12th, 13th and 14th NPC plans (2011-2019) focused on specialist services for people affected by conflict, disasters and violence; community outreach through mental health camps; and inclusion of mental health in health awareness programmes.However, the 15th plan (2019-2024) has delineated a clear working policy to expand mental health services at all levels through community health systems complementing the National Mental Health Strategy and Action Plan target to expand community mental health programmes in 500 municipalities by 2025 (Government of Nepal, 2020b, 2021a).
Despite these positive changes, the review identified several important and continuing gaps pertaining to structural stigma and discrimination, which limits the rights of persons with mental health conditions.These notable gaps and recommendations to address these gaps are described as follows:

Use of stigmatizing language and lack of clear definitions
Terminology and language in policies are indicators of structural stigma, as they expose the legal environment and confirm an institution's culture and attitudes (Corrigan and Rao, 2012).While some progress has been made in revising stigmatizing language, labelling terms such as baulaaeko (insane), imprecise language (mental disease, drug abuse), devaluing terms (mentally incapable/handicapped, mentally incapacitated) and dated terminology (mental asylum) persist in several policies.Similarly, some amended policies have replaced the previous stigmatizing words 'mentally unstable/insane' to 'of unsound mind' .Although this terminology and its definition encompasses both mental and physical incapacity, the policy and strategies formed on its basis primarily affects those with mental health conditions, reinforcing negative attitudes and behaviours, resulting in barriers to healthcare and legal services due to self, public and structural stigma (Szwed, 2020).
Another notable gap was the lack of definitions for mental health-related terminology.Due to the lack of mental healthspecific legislations or policies, definitions on mental health, mental disability, psychosocial disability, mental disorders/conditions or mental health services were absent, although many documents used these terms and have specific provisions related to them.For instance, the Social Security Act includes disability benefits for persons with disabilities, where one of the conditions listed is 'mental unsoundness' , but it remains unclear which mental health condition or functioning level qualifies for the benefit (Government of Nepal, 2018i).The Disability Act of Nepal incorporates mental and psychosocial disability and defines disability as a 'long-term impairment' (Government of Nepal, 2017a).Yet, questions persist about whether the act captures people with non-chronic mental health conditions that can still be debilitating and discriminatory.The definition for mental or psychosocial disability in the policy pertains to 'problems arising in brain' that hinder intellectual activities.Although there may be room to argue that use of biomedical definitions and classifications of mental health conditions may increase stigma, lack of clear definitions can make policies and strategies less actionable and measurable.Similarly, the use stigmatizing or vague terminology may have contributed to the use of inconsistent language regarding individuals with mental health conditions in different policy documents.
Recommendations: Immediate policy revisions are essential to eliminate stigmatizing language and promote person-centred language.A regular reviewing process should be established to prevent retention of problematic terms.There is an urgent need to add standard definitions of key terminology in mental health-related policy documents to ensure consistency and understanding.Including PWLEs in policy revision and development can enhance their rights and reduce structural stigma in policies.

Inconsistencies within and between policies limiting the rights of people with mental health conditions
Several inconsistencies were found both within and between the policies.The Disability Act states that a person with psychosocial or mental disability not to be held in prison for treatment or protection.However, the Army Act allows holding individuals in prison or mental hospitals until the recommendation of the mental hospital or prison chief for release (Government of Nepal, 2006).Similarly, the Police Act permits taking charge of 'lunatics' unable to care for themselves as part of their 'duties' (Government of Nepal, 1955).Some policies disqualify a person from a position or candidacy if 'insane' or 'of unsound mind' (Government of Nepal, 2017c).Additionally, the National Civil Code Act prohibits persons with mental health conditions from marrying (Government of Nepal, 2017d).These provisions contradict health and social policies like the Disability Act and the Constitution of Nepal, which grants equal access to public services and facilities for persons with disabilities.Contradictions are observed between national and provincial health policies.While the national strategies and action plans for mental health and NCDs focus on expanding community-based care, Gandaki Province emphasizes out-and inpatient services in district hospitals and urban clinics only, and Karnali Province prioritizes specialist health camps in remote areas (Government of Nepal, 2021e, 2019d).
Another inconsistency noticed was lack of provisions for people with substance use disorders in many health and mental health policies.Most of the health policies focused on AUDs specifically, while sparingly discussed any provisions for promotion of health and wellbeing of people with drug/substance use.This could be because use and possession of drugs is criminalized under Nepal's law and falls under the directive of MoHA rather than Ministry of Health or Social Welfare.This substantially limits the rights of people living with substance use disorder, restricting their access to health and rehabilitation.
Recommendations: Reviewing policies for inconsistencies within and between national policies is crucial.A mental healthspecific act or policy could establish a standard for formulating mental health provisions in other policy frameworks.In the absence of such policies, closely related ones like the Disability Act that are based on international conventions such as the UN Convention on the Rights of People with Disabilities (UNCRPD) can serve as a standard to promote the rights of individuals with mental health conditions.

Inadequate integration of a mental health agenda in the broader national policy framework
Inclusion of low-priority programmes like mental health into broader health or development policy facilitates optimizes available resources and enhances successful implementation of mental health programmes (Faydi et al., 2011).Despite the mental health strategy's call for integrating mental health agenda into relevant policies, the current policy framework exhibits significant gaps.While some integrations have occurred, such as in the basic health service package, standard treatment protocol and the NCD action plan, development policies related to social security, employment, education, housing, poverty, and sexual and reproductive health remain noticeably silent.
Recommendations: Highlighting the intersectionality of mental health in various health and social sectors and thereby facilitating the achievements of national and international goals such as Sustainable Development Goals may facilitate the integration of mental health into multiple development policy frameworks.

Deviations from international protocols and conventions
Several deviations from the guiding principles of UNCRPD and Universal Declaration of Human Rights were seen in the policies.Instances were found where legal capacity was undermined based on 'incompetence' in the policy documents like Impeachment Act (Government of Nepal, 2002a) and National Civil Code Act (Government of Nepal, 2017d).In the absence of a mental health act, policies lack provisions against involuntary and forced treatments that are common in patients with mental health conditions, where consent cannot be provided (Government of Nepal, 2018f).However, no assisted decision-making safeguarding the rights of persons with disabilities are mentioned in the policy documents, in contrast to the Article 12 of the UNCRPD (Alston, 2017).
Recommendations: As a country that has ratified UNCRPD and its optional protocol, Nepal must adhere to and report on the compliance of state policies with the protocol.UNCRPD in the past has raised issues regarding assisted decision-making in policies, and Nepal committed to establish legal measures for supported decision-making to ensure fundamental rights (United Nations Committee on the Rights of Persons with Disabilities, 2018).Central and provincial mental health units and legal bodies should prioritize policy review in line with UNCRPD and fulfil the commitments to the UN.Involvement of advocacy groups in policy reviews and evaluation can enhance compliance with the and meet the needs of PWLEs.Similarly, international agencies, UN bodies, advocacy groups and national stakeholders can facilitate in overseeing effective policy revision and implementation.

Lack of reliable financing mechanisms for the implementation of mental health strategies and action plans
Feasible financing mechanisms are imperative for effective policy implementation.However, the reviewed policies lack cost-effective interventions, sustainable budget planning and identification of funding sources.Although holistic services and training in effective psychosocial support and counselling are prioritized, the annual health programme operation guidelines allocate limited resources for psychosocial support and rehabilitation, prioritizing prescriber training and psychotropic medication purchases (Government of Nepal, 2019c, 2019b, 2021c, 2021d).Furthermore, while disease burden assessment is reported in the policies, there remains a gap in assessing financing arrangements and microfiscal aspects that are critical for successful policy implementation.Consequently, budget allocation for mental health programmes appears ad hoc and fluctuates annually, lacking sustainability, as evident in the annual operation guides.
Recommendations: To ensure successful implementation and sustainability of the mental health action plan, feasible funding mechanisms need to be identified.Inter-sectoral collaboration and budget planning among responsible sectors for mental health policy implementation can facilitate cost sharing, preventing undue burden on one sector.The inclusion of mental health into ongoing health insurance schemes has been identified as an effective strategy for low-and middle-income countries (Chisholm et al., 2019).Although in a nascent stage, Nepal has currently scaled up its national health insurance scheme that includes limited specialist mental health services (Government of Nepal, 2018c).Exploring insurance scheme reforms to include evidence-based treatments, securing alternative domestic resources (e.g., excise taxes) and leveraging support from international communities can offer additional funding avenues for mental health programmes.Designing pilot projects that evaluate the feasibility, cost-effectiveness and scaling-up of the interventions should be prioritized by the government and related stakeholders.

Limitations of the study
The review included unclassified policy documents from three government websites.Although we selected the three main government bodies responsible for health, social welfare and legal codes, other websites and sources may have relevant documents, leading to potential gaps in the review's comprehensiveness.For instance, National Adolescent Development and Health Strategy, 2018, was not identified during the review process (Government of Nepal, 2018b).Similarly, we missed a large body of legal documents pertaining to Drugs and substance use, which are listed under MoHA rather than Ministry of Health.Additionally, we were unable to categorize which policies supersede others when there are conflicting rights and restrictions between policies.We tried to address this by reaching out to relevant stakeholders and policymakers to share relevant policy documents and check for the inclusion of overridden documents.We also acknowledge subjectivity of the review process, despite involving multiple reviewers in the process and using framework guided by tools like WHO checklist for policy analysis and QualityRights.We tried to address this through specific inclusion criteria, search strategies and periodic review of subsets of controversial policies.Decisions were made through discussion and consensus.The analysis did not cover policy implementation, leaving room for future research on implementation status.

Conclusion
This review assessed public policies, legislations and guidelines endorsed by the Government of Nepal to understand how structural stigma and discrimination.Positive attention to mental health in recent social welfare and general health policies amended terminologies and attention to integration of mental health into basic health services.However, several gaps that contracted the rights of PWLEs were observed, including retention of stigmatizing terminology, unclear definitions, inconsistencies within and between policies that contracted rights and liberties of PWLEs, and deviations from international conventions such as.Moreover, the mental health agenda was missing in larger development policies, and financing mechanisms were lacking for sustainable implementation.Routine policy revisions to amend stigmatizing language and provisions that restrict the rights of PWLEs, integrating the mental health into larger development policies, and aligning with international protocols may help reduce mental health-related structural stigma and discrimination in Nepal.

Figure 1 .
Figure 1.PRISMA search strategy for scoping reviews.PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Table 2 .
Policy documents included in the review the right of every person to live in a secure and dignified life, to prevent and control violence occurring within the family and for matters connected there with and incidental there to making such violence punishable, and for providing protection to the victims of violence; with an objective to provide updated, evidencebased clinical recommendations outlining a public health approach to providing antiretroviral (ARV) drugs for HIV treatment and prevention in the context of the continuum of HIV care, Ministry of Health and Population, National Center for AIDS & STD Control revised the National ART Guidelines developed in 2012, based on the recommendations adopted to Nepal context from WHO 'Consolidated Guideline on The use of ARV Drugs for Treating and Preventing HIV Infection'

Table 3 .
Categories of stigmatizing language and policies endorsing them

Table 4 .
Interventions highlighted in policy documents in key areas and populations -Review of curriculum of health education

Table 5 .
Examples of policies that disqualify or restrict individuals with mental health conditions from positions or services •

Citizen Investment Trust Act, 2047 (1991) and Cooperatives Act (2017):
Person not eligible for nomination or election for positions within organization/institution if 'insane or mad', 'mentally incapable'.Ineligibility for appointment in the Post of Judge if 'having mental disorder'.Termination of the post if the medical board determines that the judge is unfit to perform the duty due to physical or mental illness.