When on July 6, 2021, Nigeria’s House of Representatives passed a bill to repeal the 1958 Lunacy Act, it was a major milestone for the country. Earlier, in December 2020, the Senate had already passed the same bill, thus making the lower chamber’s vote the final act in this piece of legislation before presidential assent.
When signed into law by President Muhammadu Buhari, the new Mental Health Law provides for the establishment of a Mental Health Department that will promote and protect the rights of persons with mental health challenges as well as intellectual, psychosocial or cognitive disabilities. This is with the view to improving the regulation of mental health services in Nigeria.
Prior to the passage of this bill, Nigeria was governed by an outdated mental health law which had been in existence since 1958. Indeed, the earliest mental health legislation in Nigeria was the Lunacy Ordinance of 1916, which was modified as the Lunacy Act of 1958, applicable in the old regions. These laws were largely based on an archaic and now repealed Mental Health law from the United Kingdom. The recent National Assembly Act cites a repeal of the Lunacy Act 1964, which is most likely its federal equivalent.
The old law is criticized for approaching mental health from a wrong perspective by viewing mental health patients as insane, lunatics who only required custodial care and confinement. The old Lunacy Act defines mental illness as lunacy; and according to this law, a lunatic includes idiots and any persons with unsound mind. It was also criticized for not addressing treatment, patient protection, re-integration into society, financing, training of mental health professionals, and failing to make mental health services available to the population.
The new bill, which addresses these shortcomings, had a long journey through the National Assembly. It was first introduced in the 5th Assembly in 2003, then in the 6th Assembly in 2008, before reintroductions in the 7th Assembly in 2013 and the 8th Assembly in 2016. It was finally brought back before lawmakers in the 9th Senate by Senator Yahaya Oloriegbe (APC: Kwara State) and passed in December 2020.
Before then, Nigeria had formulated a mental health policy in 1991 with objectives to advocate, promote, prevent, treat, and rehabilitate mentally ill patients. It also committed to integrate mental health into general health services at all levels, placing primary responsibility for ensuring comprehensive access to mental health care on primary health care services and local governments. This policy was revised in 2013, but like many government policies, its objectives have not been fully implemented due to inadequate training and supervision of primary health care workers, insufficient funding, and lack of the required political will.
The gaps left by the government are being filled by non-governmental organisations (NGOs), such as faith-based and community-based organizations, many of whom have utilized voluntary contributions and resources from donors to carry out mental health projects. In fact, the 2013 mental health policy notes that NGOs should be encouraged to assist in the promotion of mental, neurological and substance abuse prevention and rehabilitation services. It also recognized the need for new legislation to ensure legal protection of patients’ rights while stipulating procedure for involuntary detention and treatment. With the passing of this bill, the changes being campaigned for appear set to become reality.
Mental Health in Nigeria
Mental health has become a huge topic in Nigeria in recent times. Psycho-social problems brought on by economic hardship, violence and social unrest have exacerbated mental disorders.
Several reports quoting the World Health Organisation (WHO) say that one in four Nigerians (about 50 million people) suffer from a mental illness. The National Strategic Health Development Plan II (2018-2022) also mention that 1 in 5 persons would experience a significant mental health problem in their lifetime requiring long-term commitment to treatment. Unfortunately, mental health services are inadequate in Nigeria with the Association of Psychiatrists of Nigeria stating that there are only about 250 psychiatrists serving the whole of the Nigerian population of more than 200 million.
One of the ripple effects is that quacks and amateurs have taken over mental health care, often abusing the human rights of their patients. Stories of abuse, torture, and chaining of mentally ill patients by faith-based and traditional healing centers, rehabilitation centers, and even psychiatric hospitals, abound. In 2019, the Human Rights Watch did a story on the terrible abuses and psychological distress mentally ill patients were subjected to in so called treatment centres. When a media exposé on some Islamic schools/rehab centres who abused their wards came out in 2019 forcing the police to make arrests, the presidency issued a statement saying that “No responsible democratic government would tolerate the existence of the torture chambers and physical abuses of inmates in the name of rehabilitation of the victims.”
However, the government has more work to do than making statements, one of which is providing adequate financial resources for mental health services. Reports show that mental health issues do not receive priority budgetary attention. Only 3.3% of federal health budget goes to mental health, with 90% of it spent on tertiary care. Only 8 federal psychiatric hospitals serve the country while there are fewer than 15 state-run neuropsychiatric centres.
The strategic health development plan acknowledged acute shortages of skilled human resource at tertiary level and absence of non-specialised skills at lower levels of the health system to detect and manage mental health problems. Among skilled human resources sorely needed are psychiatric nurses, clinical psychologists, social workers, neuro-physiotherapists and occupational therapists.
Public attitude, stigma, and discrimination against persons with neurological and mental health conditions compound their problems. There is still widespread belief linking mental disorders to supernatural causes such as witchcraft, demonic possession, and punishment from gods.
A 2020 survey by the Africa Polling Institute (API) found that there is a poor perception about mental health in Nigeria. Drug abuse, sickness of the mind and possession by evil spirits were identified by many as the three major causes of mental illness. Findings from the survey revealed that 70% of Nigerians believe mental health disease is, “When someone starts running around naked”; while 63% were of the opinion that it is “When someone starts talking to himself or herself.”
Criminal laws (Criminal Code Act and Penal Code) criminalizing suicide and stipulating prison terms and fines for offenders has not helped matters. The provisions of the old Lunacy Act did very little to promote proper understanding and awareness of mental disorders. It also allowed exercise of discretionary powers by medical practitioners and magistrates to determine who was mentally ill and have them confined. According to health experts, the old law failed to define ‘mental disorder’ or ‘mental disability’ and was overly emphatic on custodial care without adequate provision for treatment in the community. It also used what is described as highly derogatory terms such as ‘asylum’, ‘lunatic’, ‘idiot’ and ‘unsound mind’ which is against current best practice in mental health care.
According to Africa Polling Institute, there is still widespread belief linking mental disorders to supernatural causes such as witchcraft, demonic possession, and punishment from gods.
The New Act
One of the objectives of the new bill is to promote and protect the fundamental human rights and freedom of all persons with mental health conditions and ensure that their rights are guaranteed. Another objective is to promote recovery, rehabilitation, and integration of persons with mental health conditions into the community.
The bill redefines “mental health conditions” using modern international standards. It establishes a Department of Mental Health Services in the Federal Ministry of Health that will be responsible for administering the provisions of the law. The creation of a Mental Health Fund provides a repository for financing provided by the government and donors for implementing the mental health policy. Furthermore, a representative of a civil society organization working on mental health is to serve in a committee in the department, which is to be set up to receive and investigate complaints of persons admitted to mental health facilities and even make decisions on the treatment, restraint, seclusion, or discharge of committed persons. The committee is, however, subject to fundamental human rights provisions in the constitution.
The key human rights provisions in the bill include an outright ban on chaining of persons with mental health conditions, provision of equal access to work and employment opportunities, protection from forced home eviction, right to mental health services, counselling, rehabilitation, right to quality standard treatment, right to appoint legal representatives, right to participate in treatment planning, right to privacy and dignity, right to access to information, right to confidentiality and right to legal representation.
The procedure for voluntary and involuntary admission are clearly spelled out with a time frame for admissions, seclusion, or restraint. Accreditation from the Ministry is made mandatory for facilities admitting patients, meaning that rehab centres would need a proper license to operate. The bill further prohibits and criminalizes sterilization, irreversible treatments, and sexual relationship (of health workers and staff) with a patient.
It appears the bill would only have federal level application as “health” is a concurrent legislative item, and states will need to domesticate or adapt this law to replace obsolete lunacy laws in their jurisdiction.
Mental health practitioners who participated in the public hearing on the bill have commended it, saying that it will go a long way in protecting persons with mental disorders, providing for adequate budgetary allocations for mental health facilities and service providers, improving oversight and quality services and discouraging quacks in psychiatry.
Photo Credit: @SenatorIbrahimYahayaOloriegbe