Quality Rights Gujarat (QRG) is a project implemented at public mental health facilities in the Indian state of Gujarat, which caters 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. Using the WHO Quality Rights Toolkit, the assessment team were trained in recovery oriented care, the rights of persons with mental illness, effective communication skills and alternatives to seclusion and restraints.
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.
Assessment team member reading service users’ responses on ‘what helps them recover’ on the ‘hope tree’. One of the service users related, “I was confused about my role within the team, but slowly I understood what the process meant and now I feel confident after taking interviews”.
The WHO Quality Rights Tool Kit
The project uses the World Health Organization’s innovative Quality Rights Tool Kit and capacity building tools to promote human rights and establish new standards of care. The core elements of the intervention include: (i) improvements in the mental health facility environment using existing available resources from facilities and government; (ii) 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; (iii) building peer and family support programmes delivered by non-specialists; 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).
Ms. Mita Shah, a nurse at one of the hospitals, recalls her experience of being a master trainer and a change-maker at her site, “We learnt so much through these trainings, it gave us a new direction in our practice. Having discussions, conversations, constant challenging of ideas, helped us convince the staff that recovery is possible, even in cases of severe mental illness.”
helped us convince the staff that recovery is possible, even in cases of severe mental illness.”
A service user after receiving training on rights said, “The staff should talk not only to our family, but also to us about our condition, before prescribing medication to us.”
The training made mental health care professionals and service users alike aware of international conventions on the rights of persons with mental illness and also changed policies and practices to protect and promote the rights of service users and caregivers.
Nita Tank, a nurse and a master trainer shares her experience, “Earlier, I would get irritated at the sight of some of the patients here. I would make no effort to speak to them. I did what I had to do – give medicines and injections. Now things have changed, I listen and try to understand them and in doing so, make them feel heard.”
Family and Peer Support Groups
The changes introduced have also included the formation of family and peer support groups. These have proved instrumental in protecting the rights of service users not just within the facility but also in the home environment and have given hope to many families while caring for their relatives with mental illness. It was rare for service users to visit a hospital for anything other than their medication or treatment; mental health facilities have now become epicentres of community support for service users and have created leaders that support other service users in recovery.
For the first time in India QRG empowered service users to become ‘peer support volunteers’ (PSV) within mental health facilities tasked with assisting themselves and other service users in their recovery journey through the use of recovery plans, and also with forming and facilitating peer support groups.
Janki Patel, a PSV from Vadodara says, “While working as a Peer Support Volunteer under the Quality Rights project, I feel empowered that I can help others too. I have helped other service users with building their own recovery plans. I felt it has increased confidence within me too.”
Nitaben, a school teacher near one of the intervention sites, describes her experience with the SAATHI (friend) support group. “I didn’t know how to deal with my husband’s illness earlier. I used to just give him his medication and hoped that he would just keep quiet. Being a part of the Saathi group has helped me understand how to support him. I use whatever I learn through the group in my own house. I hope to build more support groups in my community and help more people through my experience.”
Nitaben comes from district with 1.2 million people and only 1 psychiatrist in the public health system. Groups such as these provide a very cost effective and easily accessible means for support for caregivers.
Quality Rights Gujarat into the future
The project team is working on a quality accreditation process which would use WHO Quality Rights Gujarat for all mental health facilities within the State of Gujarat. The project has worked with the State Mental Health Authority to make budgetary provisions for PSVs across the State of Gujarat. Peer and family support groups which have been running successfully across all six intervention sites will continue to be supported by mental health facilities.
The State plans to also introduce cafes 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 Quality Rights project has offered a paradigm shift from a medical model to recovery based care, one that acknowledges the role of service users in their care and treatment. It has created a momentum for change at the service level and the mental health system hopes to capitalize on it to make necessary changes in service delivery to ultimately improve the lives of persons with mental illness.