T

he recent disclosure of shackled mentally ill people in Budiasih, a remote village in Ciamis regency, West Java, highlights that the inhumane practice of shackling remains a threat to people with serious mental illness in Indonesia.

The international community has widely praised Indonesia for taking a critical step toward protecting the rights of people with mental health problems when it passed Law No.18/2014 on mental health in July 2014.

However, the new law does not yet have implementing regulations.

To this day, scores of mentally ill people may still be shackled out of public view in remote villages.

An estimated 400,000 people in Indonesia have severe mental health issues, as the 2013 Basic Health Survey (Riskesdas) stated that the percentage of people affected stood at 1.7 per 1,000 people.

What is alarming is that the data revealed 14.3 percent or around 57,000 people with mental disorders had been shackled in their lives.

Shackling and other improper treatment of people with severe mental disorders are common across Indonesia, partly due to limited access to mental healthcare services.

Indonesia has only around 800 psychiatrists and only 26 out of 34 provinces have psychiatric hospitals, mostly in provincial capitals, according to the Health Ministry.

Even worse, the mental healthcare service system is focused on tertiary health care, namely psychiatric hospitals. At secondary medical care facilities in regencies and in primary health centers, mental healthcare services are often not available or are underutilized although regulations state that mental health care must be integrated into primary care services.

Thus patients must go to psychiatric or mental hospitals, mostly available only in provincial capitals, though until today, eight provinces still don'€™t have mental hospitals at all.

Inadequate psychiatric competence among doctors in primary care facilities has contributed to the wide gap in mental health care services. Not all of those primary care workers are confident in providing mental health services and many blame this problem on low competence in psychiatry.

That is why most psychiatric services in primary care facilities are still focused on merely finding people with mental health problems and referring them for more intensive treatment.

They seldom provide adequate psychiatric care although most mental illnesses actually can be treated at primary healthcare facilities.

Such '€œpatient dumping'€ or refusal to treat people with mental health problems is still common at community health centers (Puskesmas) across Indonesia. Excuses range from statements that mental health is not their priority or that they are not prepared to manage mental health problems.

According to official data, only 4,182 or 46.44 percent out of 9,005 Puskesmas have a mental healthcare unit. But all general doctors in Puskesmas actually should have acquired basic psychiatric knowledge in medical school.

In many cases, mental health patients are then referred to secondary care or general hospitals at the regency level '€” where mental healthcare services are also still low.

Only 249 or 55.95 percent of a total of 445 general hospitals in regencies and municipalities offer mental healthcare services, according to the Health Ministry.

Such poor availability of psychiatric services, even at general hospitals, has led to a widespread mindset that people with psychotic symptoms such as being rowdy, feeling restless and having aggressive, angry or violent behavior, must be immediately taken to mental health hospitals.

This would be very costly and time consuming in remote communities given that psychiatric hospitals are limited to provincial capitals.

As a result, many people with psychotic problems are simply shackled in their homes or sent to solitary confinement because families are unable to provide care for their severely mentally ill relatives.

In fact, people with psychotic disorders can be treated and with proper medical therapy, they can carry out normal lives.

Poor awareness about mental health is also a factor resulting in people with mental disorders often being left untreated and even shackled.

In many areas, people consider mental disorders as a superstitious phenomenon. They depend on traditional healers, although mental illness can be cured with medical treatment.

The social stigma attached to mental health has forced many to hide their family members who are affected by mental illness, hampering their treatment.

In 2011 the Health Ministry set the goal of a '€œshackle-free'€ Indonesia by 2019. Since the start of the program up until to December 2014, the number of shackled mentally ill people discovered had reached 6,012, of whom 5,080 were released and provided with medication.

As of 2014, 28 out of 34 provinces participated in the program. Five provinces, namely Bangka-Belitung, Central Java, East Java, Aceh and West Nusa Tenggara, have passed bylaws on ending shackling practices. This is a good start.

The new mental health law can hopefully address this growing problem. The law is aimed at stopping shackling and providing better health care for people with mental disorders.

The law also encourages general physicians to make a proper diagnosis before they refer a patient who needs a specialized health service.

Under this law, the Health Ministry is striving to improve the capacity of healthcare professionals at Puskesmas and general hospitals in handling mental health problems.

Because unless Puskesmas and general hospitals get proper psychiatric capacity, and unless attitudes toward mental health patients can change, Indonesia will remain home to many individuals shackled by their loved ones.