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The Rocky Road To A Philippine Mental Health Law

On December 12, 2017, Congress, in a bicameral session, approved The Philippine Mental Health Act after a tedious line by line review of its Senate (SB 1354) and House of Representatives (HB 6452) versions. We waited with bated breath as we silently watched the proceedings and the most crucial provisions pass its sponsors’ scrutiny. It is expected that it will be signed by the President in January 2018.

 

Along with Former President Ramos’ 1998 Executive Order 470 there had been no less than 14 related Bills passed in 1989! Why has it taken 18 long years? We can only wonder why. For sure, it is a clear indication of how low a priority Mental Health has been in our country. Nonetheless, the current Bill passed in just 3 years after its submission to Congress, in record time!

 

Why do we need a Mental Health Law?

The Philippines is among the last 30% in the world without a Mental Health Law and remains to be the only ASEAN State without one. Yet, the urgent necessity for such a legislation is very clearly borne out by global as well well as local statistics. The WHO estimates that:

  • 1 in 20 individuals suffer from a Mental Health Disorder
  • neuropsychiatric conditions account for 14% of the global burden of disease.
  • among non-communicable diseases, they account for 28% of the Disability Adjusted Life Years or DALY's (a measure of the impact of a disease), more than cardiovascular disease or cancer
  • almost one million people die due to suicide every year, (globally the third leading cause of death among young people)
  • the most important causes of disability due to health-related conditions are unipolar depression, alcoholism, schizophrenia, bipolar depression and dementia
  • The global Treatment Gap is estimated to be between 76-85% for low- and middle-income countries, and 35-50% for high-income countries.

But are these statistics applicable to the Filipino population? Are we not supposed to be one of the happiest people in the world? In 2016, we placed fifth in the highest Positive Experience Index Score. Unfortunately, local studies tell a different story.

  • 32% out of 327 government employees surveyed in Metro Manila have experienced a mental health problem in their lifetime (DOH-NEC, 2006).
  • Almost one per 100 households (0.7%) has a member with mental disability (DOH-SWS, 2004).
  • Intentional self- harm is the 9th leading cause of death among 20-24 years old. (DOH 2003).

Being the third most disaster prone country in the world, we expect not only biological and psychosocial factors to place our Mental health at risk.  Climate change which has generated super storms have wreaked not only physical and economic havoc but mental health problems as well. The WHO in 2014, estimated over 800,000 people in Yolanda-hit areas had suffered different mental health conditions, with 80,000 requiring further medication and support.

Resources for mental health in the country remains severely inadequate.

  • The number of mental health professionals is extremely inadequate to meet the mental health needs of the 130 million Filipinos. (Less than 700 psychiatrists, over 1000 nurses work in psychiatric care)
  • Presently, there are only 2 tertiary care mental hospitals, one in the National Capital Region (4,200 beds) and in Mariveles, Bataan (500 beds)
  • All private mental health facilities are located in major cities.

Only 3% (2.36B in 2016 ) of a total health budget of 78.83 B pesos is allocated for mental health, 70& of which goes for hospital-based care. This brings the per capita expenditiure on Mental Health per Filipino to 18php. If limited to 30% “poorest of the poor” becomes  118php per year.

 

Why a rights-based Mental Health Legislation?

International conventions on human rights impose appropriate and globally accepted standards for human conduct. Thus, a rights-based approach to health care which recommends that a health system’s performance be evaluated from a human rights perspective has increasingly become an accepted practice. The Rights-Based Approach to Health Care emphasizes State obligations towards worldwide eradication of disparities in:

  • access to mental health care
  • quality of life
  • wellbeing and
  • freedom from cruel, inhuman, degrading treatment

 

What is a rights-based Health Legislation?

A “human rights-based” approach to health” pays equal attention to process (how people’s rights are respected within the health system) and outcome (the goal of improving health).
It begins with the rights of every citizen and invokes the duties of the State towards protecting and enhancing those rights. Protecting human rights is synergistic with improving public health.

 

The Drafting Process

Following the WHO Guidelines: Human Rights and Mental Health Legislation, the legislative subcommittee of the Philippine Psychiatric Association (PPA) drafted the Philippine Mental Health Bill according to the following steps:

  • Defining the Mental Health situation
  • Identifying the potential barriers to legislation
  • Drafting the Bill
  • Presentation and consultations with various sectors/stakeholders
  • Advocacy and recruitment of champions and sponsors

Consultations led to two major events organized by the PPA with support of the Department of Health, a pre summit and a Summit, held just about a month apart in 2014. The Pre Summit in September 2014  created subtracks for stakeholders to continue contributing to the refinement of the Bill. Consequently, the Summit of October 2014 concluded with a Manila Declaration urgently calling for for the passing of the Law. In the Summit, then Senator Pia Cayetano received the Bill for filing in the Senate. The drafters reached a total of 28 versions of the Bill before it was finally submitted to sponsors in both Houses of Congress.

The pro bono services of our media supporters gave impetus to our advocacy campaigns in print and social media as well as commercial venues. Video materials ran in mall theaters and various fora organized by the youth sector, schools and professional associations. These campaigns eventually led to very enthusiastic champions in such as Senators Sotto, Legarda, Trillanes, Aquino, Angara, Villanueva and most importantly Senator Risa Hontiveros, Head of the Senate Commitee on Health at the time of the opening of the 17th congress. In the House of Representatives, no less than 30 representatives signed as sponsors most notable of whom were VP Leny Robredo (then Congress representative), Representatives Miro Quimbo, Helen Tan, Edcel Lagman and finally our main sponsor, Representative Chiqui Roa.

Shortly after an overwhelming majority vote without abstentions in the Senate, The House version quickly moved towards its approval in the Health Committee, the Appropriations Committee onto the second and third reading. Those present on the final reading, likewise, unanimously voted for the Bill.

 

The Philippine Mental Health Act

It is “an act establishing a national mental health policy for the purpose of enhancing the delivery of integrated mental health services, promoting and protecting the rights of persons utilizing psychiatric, neurologic and psychosocial health services, appropriating funds
therefor and for other purposes”. It is a rights-based legislation invoking the right of every Filipino to be mentally healthy, access mental health care sevices and the duty of the State to ensure this thru:

  • the protection of those who have mental health conditions and their family from discrimination, cruel and degrading inhuman treatment and torture
  • defining mental health and mental health conditions emphasizing that the mentally ill have same rights as other people with a disability
  • identifying the rights of service users, carers and mental health professionals and
  • mandating the establishment of a National Mental Health Service to improve access to clinical services and community based prevention programs and mental health services at all levels of the health care delivery system
  • the establishment of a complaint and investigation mechanism against abuse
  • research development and Mental health education at all levels of our educational system
  • The creation an autonomous and funded Philippine Mental HealthCouncil to oversee the implementation of the Law
  • Appropriating funds for the implementation of the Law

 

Issues Raised

Is it timely?

A Rights-based MH legislation is not a matter of time but a matter of necessity. It is in compliance with the State’s obligations according to:

  • The Philippine Constitution which invokes as one of its principles that “the maintenance of peace and order, the protection of life, liberty, and property, and promotion of the general welfare are essential for the enjoyment by all the people of the blessings of democracy.
  • The Universal Declaration of Human Rights which although not binding, has been upheld as the international standard for human and humanitarian conduct of all States.
  • The Convention of the Rights of Persons with Disabilities in recognizing the State’s obligation to respect the human rights of all its citizens regardless of race, color, religion, politics and disability
  • The Conventon and the Optional Protocol Against Torture which require all State Parties to protect all individuals deprived of their liberty from “cruel, inhuman and degrading treatment”.

 

Is it in violation of the UN Convention on the Rights of Disabled Persons?

Critiques of the Bill have raised the issue of absolute prohibition to involuntary treatment and exemptions to informed consent. This is currently a very contentious issue receiving very serious debate worldwide, even within the United Nations. There is no consensus at the moment. The General Comment of the UN Committee on the Rights of Persons with Disabilities which espouses this position have been contested by other treaty bodies within the UN system for its absolutism.  It has been criticized by the World Medical Association and the World Psychiatric Association for its lack of consultation and non-cognizance of clinical medical realities where a person may not be able to give informed consent or has temporary or permanent loss or impairment of decision making capacity because of sensorial disturbance, organic disease/injury  or psychosis. The Bill defines temporary or permanent impairment or loss of decision making capacity and provides clear criteria where informed consent may not be necessary for treatment of mental health conditions especially neurologic and psychiatric emergencies. It also mandates a complaint, review and judicial mechanism for the prevention of abuse.

 

Should it also provide for the protection of the rights of Mental Health professionals?

Mental health professionals are one of the most legally vulnerable health professionals. We need clear guidelines as to what is ethical and unethical conduct in the practice of our profession. We need protection from adverse consequences of protecting and promoting the rights of their patients or clients.

 

How specific should the budgetary provision be?

Rightfully, Representative Lagman pointed out that “legislation is only as good as its budgetary provision and that a good Law without resources is a  toothless Law”. He fixed the wordings of the appropriations provision of the House version to specify that the implementation of the law  be part of subsequent General Appropriations Act for Health together with savings from 2017 and 2018 approved budgets. The Senate Version, on the other hand, provided for the allotment of five percent of Sin Tax for this purpose. We were pleasantly surprised that the Bicameral deliberations resulted in a consensus for adapting both versions.

 

Creation of a Philippine Mental Health Council

To ensure its autonomy and power to implement the Law this provision was scrutinized in the Bicameral session. What are its powers and functions? Under whose jurisdiction should it be? What will be its composition Composition? Who will appoint its members? What resources will it have?

The Chair of the Council shall be the Secretary of Health who will nominate a list of nominees from among designated stakeholders to be approved and appointed by the President. The Law will provide for the creation of a “Division on Mental Health” which will serve as the secretariat of the Council. The Council is empowered to determine the use of funds provided by the Law.