Presentation from the International Congress of the Royal College of Psychiatrists 24-27 June 2014, London

1. Safeguarding the Rights of Mentally Ill:
Experience from Sri Lanka
Sherva Cooray
Consultant Psychiatrist
Global Mental Health:
Learning from Low and Middle Income
(LAMI) Countries
International Congress of the Royal College of Psychiatrists
24th-27th June 2014

2. Acknowledgements-
Dr Jayan Mendis,
Director,
NIMH (National Institute of Mental Health)
Sri Lanka

3. Presentation Outline
• Background Issues
• Sri Lanka and Safeguarding Mental Health-
yesterday, -today ...and beyond...
• Key achievements- omissions- commissions
• The Diaspora-RCPsych-Sri Lanka – towards achieving
excellence

4. Sri Lanka-About...
• Population ~ 20,000,000
• Emphasis: prevention and public health
• Life expectancy 70 years++: Exemplary (WHO)
• Country of Contrasts-(???Mental Health)
• Man made & Natural disasters-
Viz. Ethnic and civil unrest latter 20th Century-2009,Tsunami 2004

5. Sri Lanka-About: History
• Healthcare-5000 Years-RAVANA
• First Hospitals established-4th Century BC-
(Pandukhabhaya)
• Community Care
• Holistic system- mind and body(eg. Ayurveda)
• 1505 AD- Colonial system

6. Healthcare in SriLanka-Post colonial-1948-
• Very high standards of health development-(WHO)
• 2% of Gross Domestic Product (GDP) Public Health
• Free Universal Healthcare- Womb to Tomb-
• ~ 60% of the rural population relies on traditional and natural
medicine for their primary health care

7. Sri Lanka-Mental Healthcare
• Ranks among highest suicide rates in the world
1995= 47/100, 000*
2009= 19.6/100,000*
*DeSilva, V et al 2012
Yet
• MENTAL HEALTH IS AN “ORPHAN”
• Archaic Mental Health Legislation-(Lunacy Ordinance of
1873-
• minor modifications in 1956

8. Violence against women is prevalent in Sri Lanka*
• 36% of ever-partnered men reported perpetrating physical and
or sexual violence against a female intimate partner.
• 6%of all men perpetrated sexual violence inclusive of rape
against a non-partner woman
• 17 % perpetrated sexual violence inclusive of rape against any
women.
Despite
• 1st Asian queen regnant-(47 – 42 BC): Anula-Black widow-
serial killer
• First woman Prime minister-1960- Sirimavo Bandaranaike
*Broadening gender: Why masculinities matter -2013

9. The Tsunami 2004...and Aftermath
• Mental Health Policy-2005
• New Mental Health Legislation- drafted 10+
Years ago!
• Passed by parliament-2014
• WHY DELAY???

10. Safeguarding-Principles and Sri Lanka:
? Emerging Green shoots
• Principle 1 – Empowerment
Presumption of person led decisions and consent
• Principle 2 – Protection
Support and representation for those in greatest need
• Principle 3 – Prevention
Prevention of neglect harm and abuse is a primary objective.
• Principle 4 – Proportionality
Proportionality and least intrusive response appropriate to risk
• Principle 5 – Partnership
Local solutions via services working with their communities
• Principle 6 –Accountability
Accountability and transparency in delivering safeguarding

11. Mental Health Policy Sri Lanka 2005-2015-Highlights
To provide mental health services
• Universal High quality-Evidence based where and when needed.
• Organized at community level with consumer participation.
• Linked to other sectors of healthcare services
• Culturally appropriate
• To protect the human rights and dignity of people with mental
illness.

12. Mental Health Policy- 2005: Key Principles
1. Provide services- Primary, Secondary Tertiary Levels
2. community based–
3. Enshrine consumer participation.
4. culturally appropriate
5. protect human rights and dignity

13. Sri Lanka Mental Health Policy-Progress
•Approved by the Cabinet in November 2005-Updated
2010
•The Ministry of Health & WHO
Capacity Building
–infrastructure, –human resources development
-seeking technical assistance
-scientific support for training and –curriculum
development

14. What of Sri Lanka? Low Priority-Why?
• Lack of awareness and knowledge about mental disorders
• The lack of knowledge about the extent of the burden/
Presence of cost effective interventions
• Stigma
• Misconceptions/Prejudices /Beliefs -causes and the nature of
mental health conditions- “possession”-Weak/Lazy/
dangerous
• underinvestment in mental health services as well as a
number of different human rights violations- Low human
resources
Michelle Funk-WHO

15. Human Rights-Sri Lanka
• Party to the 4 1949 Geneva Conventions but not their
additional protocols.
• Ratified a number of other IHL treaties, including the 1980
• Adhered to many human rights treaties (but not their
verification mechanisms)
• 2 international Covenants and the 1989 Convention on the
Rights of the Child and its optional protocol on the
involvement of children in armed conflict.

16. Mental Health Services Distribution 2004-2012
Things they are a changing!

17. GBV Prevention Team- NIMH
011-2578234 Ext- 294
Dr Pushpa Ranasinghe GBV 2012 NIMH

18. Previous Seclusion
Separate Seclusion areas

19. Grandma receives the injection
Home Visits

20. Launched 16th December 2009
Mental Health Help Line-1333 –
(NIMH World Vision Collaboration)

21. RAISING THE PROFILE
Rights for People with Mental Illness
2008-
NIMH Sri Lanka

23. Opening of the
Community Outreach
Clinic
For
People with Mental
Health Problems
Wadduwa,
Sri Lanka
2008
Now managed by the
NHS
Sri Lanka

24. 2010-2012
Professor Rachel Jenkins
Dr Sherva Cooray
Dr Jayan Mendis
mhGAP Training
2013
Professor Sab Bhaumik
Dr Sherva Cooray

25. Towards sustainable Capacity Building
“The art of the possible”
PARTNERSHIPS – Sri Lanka-The Diaspora- RCPsych
• Education and Training
• Long Distance Mentoring-”Adopt” a Colleague/s
• Share Mutual Expertise-(Medical Partnership
Initiatives)
• The MTI
• Sabbaticals

26. What did I learn??
A LOT...
and still learning
• There's more than one way to skin a cat
• Resourcefulness & Resilience trumps Adversity
• How did they do it???
• When “despondent-”
Bat SERENDIPITY 24/06/2014