QualityRights Gujarat Project (QRG): an innovative intervention to improve public mental health services in Gujarat, India, by reorienting services from a purely medical approach to a holistic, comprehensive and participatory approach that values and emphasizes empowerment, autonomy, recovery and an integration into the family and community.
By Jasmine Kalha, Sadhvi Krishnamoorthy and Titus Joseph (researchers with QualityRights Gujarat, Centre for Mental Health Law and Policy, Indian Law Society, Pune), Michelle Funk and Natalie Drew (Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland) and Soumitra Pathare (Psychiatrist, Coordinator of Centre for Mental Health Law and Policy, Indian Law Society, Pune, Principal Investigator QualityRights Gujarat).
QualityRights Gujarat Project (QRG) is an innovative intervention to improve public mental health services in Gujarat, India by reorienting services from a purely medical approach to a holistic, comprehensive and participatory approach that values and emphasizes empowerment, autonomy, recovery and an integration into the family and community.
The project was implemented at public mental health facilities in Gujarat, which cater to marginalized and vulnerable populations with mental illness. Gujarat has been at the forefront of mental health reforms in India and it pioneered a State Mental Health Policy in 2003. Nevertheless, ongoing challenges to efforts to implement this legislated policy led to the introduction of QRG in 2014 with a clearly stated commitment to tackle the lack of quality provision and human rights violations within mental health care.
QRG started with baseline assessments at six intervention sites, and three control sites. The assessment team members included service users, caregivers and mental health care professionals. The project uses the World Health Organization’s innovative QualityRights Tool Kit and capacity building tools to promote human rights and establish new standards of care. Full engagement of service users from the very start, who are inspired to become active participants in their own care and treatment, is an ongoing key element of the programme and one which has significantly strengthened its outcomes.
QualityRights Gujarat Interventions
The core elements of the intervention include:
- improvements in the mental health facility environment using existing available resources from facilities and government;
- training 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;
- building peer and family support programmes delivered by non-specialists; and
- introducing facility-level policy and mechanisms to govern practices to protect against inhuman, degrading treatment, violence and abuse (including the use of restraints).
The project built local capacity by using the master trainer model, covering approximately 407 mental health care professionals across six sites trained on recovery oriented care, 447 on rights of persons with mental illness, 424 on effective communication skills, and 286 on alternatives to seclusion and restraints.
The innovation also inspired and empowered service users to become active participants in their own care and treatment. By using the peer support volunteer model, it also helped them to become advocates for change with their personal stories having a powerful influence on decision makers at the State Department of Health and Family Welfare. The introduction of PSVs was a unique innovation of the project that included persons with lived experience to assist other service users’ in their recovery journey using recovery plans.
Impact and future of QR Gujarat
The State Government has now decided to expand QR to the three control sites using staff from the original six intervention facilities to expand the project. Furthermore, peer and family support groups, which have been running successfully across all six intervention sites, will continue to be supported by mental health facilities. In the past year, the Department of Health and Family Welfare, Government of Gujarat State, has expanded peer support initiative by funding 50 peer support volunteers in the State of Gujarat along with a commitment to increase this funding in coming years.
The innovation has influenced the heads of the participating mental health facilities and State Government to support the continuation and expansion of the programme within Gujarat state, through training key workers and ring-fencing budgets for psychotropic medicines.
The State plans to also introduce cafés run by NGOs and employing persons with mental illness at the public mental health facilities, to address financial independence and reduce stigma towards mental illness.
The QR team is working on a quality accreditation process using the WHO QualityRights Toolkit for all mental health facilities within the State of Gujarat to reward achievements and provide an incentive. The innovation has already led to facilities achieving prestigious awards: in 2016, one of the nurses trained through the QR innovation received the nation’s prestigious National Florence Nightingale Nurses Award – the first mental health nurse in India to have won the award.
The QR innovation is also spreading to other Indian States. The QR Gujarat team has been contracted by the Tata Trusts to implement the QR innovation in Nagpur Mental Hospital in the neighbouring state of Maharashtra.