On July 8, a day before Indonesia held its presidential election, the parliament passed the bill on mental health into law. The election coverage drowned the news of the new law, but not its significance.
Thousands of people in Indonesia are subjected to shackling by families who lack knowledge and resources in caring for people with mental disorders. The new law aims to stop this.
The legislation spells out a more comprehensive approach to mental health treatment and creates a legal obligation for the government to protect people with mental disorders.
People in chains
According to 2007 basic health research, some 19 million people in Indonesia suffer from depression and anxiety. Around a million people have psychosis.
People with mental disorders in Indonesia suffer from neglect, violence and discrimination. The health ministry estimated that in 2013 more than 57,000 people, mostly in rural Indonesia where health services are scarce, were living in shackles.
Families are usually the initiators of confining people with mental illness. To “protect” patients and the community from aggressive and violent behaviour, families resort to physical restraints.
In remote villages, parents and siblings chain family members in the back of their homes or backyard shacks. In big cities, victims are locked in small rooms. Often families also neglect basic needs such as proper sanitation, food, and clothing.
In 78% of the cases, pasung, the local term for the practice, becomes the last resort after bringing the person for treatment.
Reasons for pasung
A number of studies on pasung have shown that the practice occurs because of the lack of adequate knowledge of mental health in the community and poor health services.
Indonesia has 47 mental health institutions and around 800 psychiatrists. This may seem a lot, but more than half of the country’s mental hospitals are concentrated in four out of the country’s 34 provinces. Eight provinces have no mental hospitals.
Further, only 30% of around 9,000 local community health centres across the country have mental health services and 10% of these are in Aceh province.
Many people living in rural areas believe mental illness is caused by black magic. Instead of seeking mental health treatment, they take their family members to shamans to be cured of “curses”.
Families also face difficulties in accessing mental health services. They associate treatment with expensive mental hospitals far away from their homes. In addition, mental institutions have a bad reputation for having few resources and being overcrowded.
These problems are compounded by the absence of continuous mental health services from hospital to the community after the patient has been released.
In addition, mental health efforts still focus on curative aspects. This strategy does not address ways to help people with mental disorders to be productive nor tackle the economic burden faced by caregivers and families.
Indonesia banned pasung in 1977. In 2011, the government ratified the Convention on the Rights of People with Disabilities (CRPD). A year earlier, it launched a campaign to eliminate the practice of pasung by 2014.
The government will likely miss its target due to lack of funding and professional health workers. But 23 provinces have joined the campaign and committed to eliminating the practice in their areas.
The legislation is a welcome and much-needed boost in tackling the problem of pasung. But it requires every province to have at least one mental hospital. Under the law, mental health care is a government responsibility all the way to the district and municipal levels.
The law also regulates promotion of mental health and rehabilitation to be carried out by families, education institutions, workplaces, media, religious organisations and prisons. This involves various ministries beyond the health sector, as it should.
To eliminate pasung, there needs to be an integrated and comprehensive mental health system, supported by multiple stakeholders.
To ensure systemic improvement, various ministries and local government will have to allocate budgets for mental health care to implement the law. The current 1% budget allocation from the health ministry is gravely inadequate for tackling the country’s mental health issues.
The development of a better mental health system has only just begun. Now everyone - policy makers, academics, public and private mental health service providers and families - must take part in making sure the new law is implemented.
And a good monitoring and evaluation system should be developed to ensure we meet our obligation to free all shackled souls.
This piece was co-authored by Albert Maramis, mental health and psychosocial support consultant at the WHO Country Office for the Philippines