Innovation summary

Poor quality and human rights violations are a feature of mental health services in facilities across India. Treatments provided are not in line with evidence and best practice and many service users are exposed to inhuman and degrading treatment, restraint, seclusion and physical, sexual, and emotional abuse and neglect.1

The proposed project provides a solution in the State of Gujarat, India, by introducing and scaling up an innovative QualityRights intervention in mental health facilities. The project will utilize WHO’s QualityRights Tool Kit2 and framework3 to first conduct an assessment of quality and human rights in mental health facilities and then to implement an intervention that improves facilities and mental health outcomes.


Impact summary

  • 49,500 people with mental disorders per year exposed to the innovative service model and accessing better mental health services
  • People with mental disorders at the 6 intervention mental health facilities experiencing a 20% reduction in disability and improvement in functioning by the end of the project
  • Cost per unit reduction in disability and improved functioning as measured by the Sheehan Disability Scale

“Why should we tell what the service users should do? Let us ask what they want to do” 


- Nurse, at a mental health facility after a training session as a part of the intervention

This project is funded by Grand Challenges Canada 

Innovation details

QualityRights Tool Kit Overview

The project uses the WHO’s innovative QualityRights framework and Tool Kit to promote human rights and establish new standards of care across 5 interrelated areas which have a positive impact on the quality of services and promote respect for human rights.

The core elements of the intervention include:

  1. Improvements in the quality of services and living conditions in facilities using existing available resources from facilities and government
  2. Training for health workers, service users and families on human rights in order to promote changes in attitudes and practice towards a recovery approach which enhances autonomy and engages service users in recovery plans
  3. Building peer and family groups delivered by non-specialists
  4. Introducing facility-level policy and mechanisms to govern practices to protect against inhuman, degrading treatment, violence and abuse (including the use of restraints)

The Tool Kit establishes standards of care which can be applied in a culturally and socially appropriate manner across five interrelated areas; each addressing an important human rights and quality issue:

  1. Promoting inclusion and independent living in the community. This means establishing links to community services and building support networks, for example, through family and service user peer support workers and groups. This is important to prevent relapse and promote social inclusion, recovery, and integration into community.
  2. Protecting against inhuman and degrading treatment, violence and abuse. This includes introducing measures, for example, to document, report and prevent violence, abuse, punishment and neglect, finding alternatives to seclusion and restraints and over-medication.
  3. Promoting legal capacity and enhancing autonomy. This means ensuring that service users remain central to all decisions that affect them, for example, by enabling service users to participate in the development of their treatment plans and to make informed decisions concerning their care.
  4. Promoting the highest attainable standard of physical and mental health. This means reorienting the practices of health workers towards providing a holistic, recovery oriented care and rehabilitation rather than focusing solely on medication to reduce symptoms.
  5. Promoting an adequate standard of living, for example, ensuring that the environment is caring, supportive, comfortable and stimulating.

These interventions will be implemented at six mental health facilities across the State of Gujarat, India, including outpatient and inpatient units at mental health hospitals and psychiatric departments within academic medical centers and district general hospitals.

Project implementation outline

The broad outline of project implementation is as follows:

(i)     Established Advisory Group and Management Team

As a first step, an Advisory Group was set up, bringing together representatives from the State Department and Federal Ministry of Health and Family Welfare, human rights advocates and senior mental health professionals. A project Management Team was also set up including the project team and the heads of mental health facilities where this project is being carried out.

(ii)    Established implementation plan

The implementation plan covered the detailed planning and scheduling required for the development and implementation of the project, ranging from the training of ‘assessment’ committees, the logistics of carrying out the baseline assessments of facilities, the setting up of peer support and family interventions, and the development of facility-based strategic plans and their implementation.

(iii)   Completed baseline assessment

Baseline assessment for individual outcomes: Service users, family members, and health care workers were assessed on measures related to disability and functioning, knowledge, attitudes and practices in relation to their condition and human rights, as well as satisfaction with services. 

Baseline assessment of mental health facilities:  All services in the intervention and control group underwent assessment using the WHO QualityRights Tool Kit to measure the degree to which mental health facilities meet the standards and criteria in the 5 domains of the WHO Tool Kit.

The assessment was conducted by trained visiting committees made up of health professionals, persons with mental disorders, family and non-family care givers, human rights advocates and representatives of NGOs working in the field of mental health.

(iv)   Implementation of interventions

The QR Intervention:  Based on the results of the assessment, workshops have been conducted to feed back and discuss findings with health-care workers of the facility, service users, and families. Facility based strategic plans have been developed to address gaps in the five interrelated areas of QualityRights for the intervention group facilities, using a participatory approach through discussions and workshops. Capacity building will also be carried out through training sessions on human rights in mental health, recovery oriented mental health care, communication skills, and alternatives to seclusion and restraint in psychiatric care. Peer support groups for service users and caregivers are being set up and leaders for each type of group are being identified and trained. Peer support workers are also being recruited and trained.

At each intervention site, two QualityRights Champions have been identified (from within the health care staff) who will receive special training at CAMH to observe and learn how quality and rights interventions can be integrated into service delivery and sustained over time. Health workers will serve as change agents and service users and families will help maintain quality control.

(v)    Follow-up assessment

The follow-up service assessment of the intervention and control facilities using the WHO QualityRights Tool Kit will be done on completion of the intervention. Service users, family members and health workers will undergo a follow-up assessment on the measures of disability, knowledge attitudes and practices, and service satisfaction outlined above, 6 months post intervention.

(vi)   Dissemination and further scaling up

The overall communication objective is to highlight the importance and impact of scaling up quality and human rights in mental health services. Dissemination of information will be interactive, engaging with the target populations, and involving influential figures, national mental health champions, policy makers, politicians and civil society.    

At the start of the project, a state-level meeting was held to officially launch the project, bringing together high-level representatives from local government along with other project stakeholders, in order to raise awareness on the project and promote national ownership. The media was invited to attend and a press conference was held.

At the end of the project a conference will be organized, bringing together stakeholders involved in the project as well as health workers and managers, service users and families from ‘non-project/intervention’ services in Gujarat and other States in India, with an interest in implementing the integrated service model in their facilities. International mental health advocates and representatives from other countries will also be invited to participate in the conference


Key drivers

Governmental Involvement

  • The government of Gujarat’s recognition of the need to improve quality of health services in the State and in respecting the rights of persons receiving treatment has been instrumental for the successful implementation of this programme. 
  • Pre-existing factors that also enhanced implementation include a dedicated budget for mental health and a favorable environment within facilities for change.
  • The involvement of the Department of Health and Family Welfare is also critical for enhancing the sustainability of the project.



We are impressed with the level of motivation of the public mental health staff involved in clinical services at the facility level and their desire to bring about changes which will positively impact the lives of persons with mental disorders. The challenge is to maintain this level of motivation in the presence of issues which are largely beyond the control of either the project team or those in charge of running the facilities. To cite just one example, senior staff members (eg Nursing heads) at some of the facilities have been transferred as part of the routine governmental policy of rotating staff between facilities. This however has a demoralizing effect on other staff members and the attendant risk that this negatively impacts their work.



The QualityRights intervention can be scaled up in low-resource settings in a sustainable way beyond the project lifespan. Firstly, the project uses and builds upon existing service infrastructure, resources and good practice, but incorporates new components in order to transform, rather than rebuild, what services are delivered and how they are delivered. The intervention is more than a simple ‘add-on’ to the existing mental health services. Rather, it transforms the delivery approach from a curative to a recovery model, based on a new service culture and a paradigm shift in the understanding and practice of the key stakeholders in terms of what it means to respect rights, to engage service users in their treatment and recovery plans, and to promote autonomy and opportunities for independent living in the community. Secondly, the project capitalizes on the wide availability of motivated informal supports to deliver effective peer support and family interventions. Thirdly, the project integrates service standards into policies governing the way facilities function.

The solution can be scaled up at national level with the transformed services created in Gujarat serving as models for services in other States of India, as well as in other low-income countries. The project can capitalize on the experience and training of key stakeholders engaged throughout the project by using them to act as agents of change and resources for scaling up in other States and countries. 


Evaluation methods

The project will use a parallel group research design in which 6 mental health facilities will be assigned to the intervention condition, and 3 mental health facilities will be assigned to a control condition. Both the experimental and control conditions will receive the QualityRights assessment, but only the intervention group will receive the integrated intervention to improve quality of care and protect human rights.

Quantitative and qualitative data on the major outcomes will be gathered at baseline and at endpoint. The following outcomes will be evaluated:

  1. Disability levels: Disability levels and overall functioning for service users will be assessed using the Sheehan Disability Scale
  2. Knowledge, attitudes, practices: Knowledge, attitudes and practices of the key stakeholder groups (people with mental disorders; families and health workers) will be evaluated in relation to mental illness, its management and to human rights.
  3. Levels of service satisfaction: Health workers, people with mental disorders and families will be asked to complete ratings to understand their satisfaction with the service provided.
  4. Quality and human rights conditions: The QualityRights Tool Kit will be used to assess human rights and quality conditions in mental health facilities for each of its domains:  (i) promoting inclusion and independent living in the community; (ii) protecting against inhuman and degrading treatment, violence and abuse; (iii) promoting the highest attainable standard of health; (iv) promoting legal capacity and enhancing autonomy; and (v) promoting an adequate standard of living  in mental health facilities.
  5. Economic evaluation: The economic evaluation will assess the costs for achieving a reduction in disability and improved functioning using the change in disability scores from baseline to follow-up as the main outcome measure.
  6. Evaluation of barriers: The project will document barriers to implementation throughout the project, as well as the solutions used to overcome the barriers.


Cost of implementation

Not yet known yet - will be later determined.  


Impact details

Not yet known yet - will be later determined.  


  1.  National Human Rights Commission (2008) Mental Health Care and Human Rights. National Human Rights Commission, New Delhi, and NIMHANS, Bangalore, India.
  2. World Health Organization (2012). QualityRights tool kit to assess and improve quality and human rights in mental health and social care facilities. World Health Organization, Geneva. 
  3. WHO QualityRights (2012). Act, unite and empower for mental health



Fortunately I have implemented QR tool kit in Afghanistan and it is really very supportive in order to find out the gaps regarding quality of services and human rights promotion.
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