By – Sunidhi Khabya

1. Introduction

The Prime Minister, on the inauguration of the 6^th edition of ‘Advantage Healthcare India’ (‘AHCI’), clarified his vision for advancing healthcare in India, stating, “India’s vision of good health implies not just being free of disease but also to ensure wellness and welfare for everyone. The goal is to ensure physical, mental and social wellbeing.”

According to the National Mental Health Survey 2015-16, “10.6% of adults in India suffer from mental health disorders, out of which 70-90% of the people with mental health disorders do not receive proper treatment due to lack of awareness, stigma and shortage of professionals.”

Amidst these bleak statistics, the worse hit group can undoubtedly be considered as the persons with disabilities [“hereinafter, PWDs] in requirement of mental health services. They suffer from a kind of double discrimination leading to multiple structural and societal barriers preventing them from getting the support they need. The gap between access to mental health services for them isn’t just societal, but it is also systemic.

1. Legal Framework Governing Mental Healthcare for PWDs

The RPwD Act, 2016 defines a person with disability as “a person with long term physical, mental, intellectual or sensory impairment which, in interaction with barriers, hinders his full and effective participation in society equally with others”. Under Section 25 of this act, the government is mandated to provide healthcare services to PWDs, free of cost. It required that PWDs have the same access to quality and affordable healthcare as provided to other persons.

While The Mental Healthcare Act 2017 under Section 18 provides for the right to access mental healthcare, according to which this right shall include access to mental healthcare and treatment of affordable cost and of good quality, which shall be available in sufficient quantity and without discrimination on the basis of any grounds, including disability or any other basis. This entails that PWDs do have an intrinsic right to mental health services, same as any other person.

The MHCA, 2017 was enacted as a result of India’s ratification of the United Nations Convention on Rights of Persons with Disabilities and the need to harmonise existing laws with this convention. This convention mandates non-discriminatory access to healthcare services, and further binds the state to ensure this access.

1. The Reality Gap – Barriers to Access for PWDs

Despite the progressive and aspirational legal frameworks, the ground reality is a chilling contrast to the proposed statutes. The cold and hard truth is that this accessibility of mental health services for PWDs still remains an unattainable dream. The issues lie not just in the statute itself, but in the lack of accessible hospital infrastructure, unaffordable therapy, inadequate and untrained professionals in handling unique problems faced by PWDs, stigma and attitudinal barriers, and, more so, the lack of agency and autonomy in people with disabilities regarding their own lives.

1. Infrastructural Barriers

The first question that arises is whether a PWD even enters the building? The problem here is infrastructural inadequacy in most of the government hospitals and healthcare centres which seldom comply with the norms required under Harmonized Guidelines and Standards for Universal Accessibility, 2021 the absence of ramps for wheelchair users and the lack of infrastructure for visually impaired individuals prevents them from easily accessing these buildings, let alone receive the requisite care despite Section 44 of the RPwD Act mandating accessible infrastructure in healthcare institutions. This presents a cruel irony for PWDs who have the rights, but no way to access them.

• Economic Barriers

The second question is whether the services are affordable. Therapy and psychiatric medication costs are high and recurring. Section 21(4) of the MHCA mandates parity between mental and physical health in terms of insurance benefits. Despite this provision, along with the guidelines of the Insurance Regulatory and Development Authority of India regarding the same, insurance companies try to limit the coverage for mental health-related hospitalisations. This situation is worse for PWDs, as many of them already grapple with employment discrimination, and additional medical bills for them become too much to bear, thereby keeping them from essential care that they so require.

• Societal and Attitudinal Barriers

The third question is whether society will allow the person to seek help. It is not a hidden fact that mental illness is still considered a taboo in Indian society, similar is the condition for disabilities, which are also seen as deviating from the societal norm. A combination of these two leads to a situation of double discrimination wherein individuals are seen as lesser humans. Families of such persons generally try to hide mental illness, and even the doctors might dismiss mental illness symptoms as a “part of the disability,” especially in the case of intellectual disabilities. This kind of ‘double discrimination’ acts as a barrier hindering PWDs from accessing their rights according to the definition under Section 2 of the RPwD Act.

• Professional Barriers

The fourth question is whether there are even trained professionals capable of catering to the needs of PWDs. For a country that has the highest population in the world, we do not have enough resources to cater to the needs of even half of them. The mental healthcare system in India is in a deep crisis, with a huge deficit in the ratio of available mental health professionals. Further, as per the “Indian Journal of Psychiatry, India has just 0.75 Psychiatrists per 100,000 people, whereas the recommended ratio is 3 per 100,000 as per the World Health Organisation.” On top of this clear deficiency, the existing professionals are not trained in disability inclusive care. Most of these professionals are not trained in sign language or braille to accommodate patients with visual or hearing impairments. Specially trained doctors, psychiatric nurses, and psychologists with disability sensitive training are needed to make healthcare actually inclusive for PWDs.

• Autonomy and Legal Capacity

The last question raised here is whether PWDs can even make their own decisions?  In many cases PWDs do not have the legal capacity to make decisions, or are able to make decisions only through the support of another individual, as provided under Section 13 of the RPwD Act, such person providing support might use their influence for personal gains against the benefit of the PWD, the provisions provide safeguard for this situation, but the lack of implementation still remains a major hindrance in ensuring rights of PWDs. Even under MHCA, 2017 provisions for Advance directive underSection 5 of the act and Nominated Representative under Section 14 serve the same purpose, that is, safeguarding rights of PWDs, but these provisions are more often than not misunderstood and misused. The will of individuals is often ignored in lieu of their “best interest”, which again remains highly subjective. So the question remains, whether a right is still considered a right when one needs a psychiatrist’s nod and a guardian’s consent to use it?

1. Intersectionality – the hidden barriers

Added to these obvious barriers are also certain latent barriers. Being disabled in the contemporary world is one battle, but for those groups who are disabled and even further marginalised, it is a whole other war to live with each day. Intersectionality thus becomes an invisible barrier towards mental healthcare for PWDs. The main sufferers of this intersectional discrimination are women, queer and trans PWDs and also disabled persons belonging from rural areas. These marginalised groups are doubly excluded and oftentimes have zero access to trained professionals.

• Recommendations for Making Mental Healthcare Accessible

The problems therefore lie not only in just the lack of services, but also in the fact that these services are designed without keeping the disabled person in mind. In order to make mental healthcare services more accessible to PWDs, the law must be governed by empathy and policies must reflect Intersectionality. Some of the suggestions to increase this accessibility are as follows.

• It is necessary to enforce the right to reasonable accommodation as provided under Section 3(5) as a non-negotiable right of PWDs. Mental healthcare services must be provided to PWDs based on their requirement and not on feasibility for healthcare providers. Reasonable accommodations such as flexible appointments, longer therapy sessions, interpreters, and non-verbal communication aids must be readily available to suit the needs of the PWDs. As held in the case of ‘Jeeja Ghosh v. Union of India’ reiterated the importance of ensuring the right to dignity of disabled persons and further their right to have reasonable accommodation and additional assistance if required. 
• It is also essential that disability sensitive training be provided to mental healthcare professionals, as most of these professionals are not trained in disability-specific needs such as sign language and braille. Further the therapy models are often urban centric and class-biased. Special training of professionals for catering the needs of PWD is required at the base level. Professionals must be trained in handling sensitive cases such as these, since their college and must have practical experiences to deal with these scenarios. Further the government must conduct training workshops and seminars for professionals to sensitise them with the problems faced by PWD and effective therapy models for them. It is important for institutions to have at least one professional trained in sign language.
• Institutions that come under the District Mental Health Programme instituted by the government must also provide disability specific state action plans to be more inclusive. Further programmes such as mobile therapy units and group therapy sessions may help elevate less serious mental health issues.
• Another step could be starting with disability and mental health rights clinics and societies at law universities. Pro bono assistance is required by disabled persons the most, such societies can help them file complaints for redressal and also make the complex legal process easier for PWDs.
• The most important change, however, is to ensure that rights are not just made ‘for’ disabled people, but they are also made ‘by’ them. These persons are best equipped to enlighten the lawmakers about ground realities, and therefore, they must be included in mental health review boards and state mental health policy design committees as well. Supported decision-making models must be there, where people with mental health disabilities lead their own career paths.
  
  Conclusion – Bridging the Void Between Rights and Reality
  India’s mental health and disability laws are progressive on paper; they promise dignity, autonomy, and parity, and they strive for inclusivity and accessibility. But for the PWDs who must navigate mental health issues on a day-to-day basis, these guarantees often fail when it comes to accessibility of hospitals and courtrooms. This is not just a gap in rights, but also a void between rights and reality, which must be filled through changes in the structure itself. This is the only way forward: to change the entire structure, not just the inaccessible services, but also the mindsets of individuals who are the major stakeholders. The law must reform itself based on the lived realities and experiences of individuals who suffer on a daily basis, to access what is rightfully theirs: mental healthcare not just as a luxury, but as a basic necessity.