A/HRC/41/34 I. Accountability 43. Accountability within the determinants of health is a particular challenge that tests the strength of governance. The right to health requires accountability across a range of domains, which can help to ensure that the action required for the promotion of mental health does not get diluted in the broader policies of other sectors. Successful accountability requires a range of elements that includes monitoring, review (judicial, quasi-judicial, political, administrative and social accountability mechanisms), remedies and methods of redress. 44. The participatory development of indicators and benchmarks to monitor progress towards the full realization of the right to mental health is essential. Indicators must move away from biomedical traditions, such as the number of diagnosed mental health conditions, beds, hospitals and specialized health workers. A rebalanced focus that equally targets population-wide determinants at the community and structural levels, such as violence, civil society and social participation, discrimination, equality and social support, is a more promising way to monitor meaningful progress.20 45. Participation forms one of the underlying tenants of social accountability, and ensures that policies are developed and reviewed with civil society central to the process. These constructive conversations are vital, and as such, civil society and user-led groups must be empowered with the resources and the space necessary to mobilize. Without such a participatory decision-making process, mental health inequalities and underlying causes cannot be addressed. J. Mental health care and support 46. While in the present report the Special Rapporteur focuses on strengthening the case for action on the determinants of health to promote the well-being of everyone, he expresses his continued concern about the status quo of the provision of mental health services, which particularly affects the promotion of the right to health for many who have been harmed, abused or left abandoned by health-care services. While the promotion of mental health requires action to support healthy and positive relationships in society, it applies equally and is of critical importance to the health-care sector itself. 47. Promoting supportive, respectful and non-violent relationships in health-care settings, especially in mental health-care settings, is a special priority for the mandate holder, correlating with the healing dimension of the health profession and the ethical requirement to do no harm. Research shows that many users of mental health services have experienced widespread forms of violence and harm while in care. This is an issue of great concern for the Special Rapporteur.21 48. Acceptable and high-quality therapeutic relationships (those between providers and users of services) must be based on mutual respect and trust. The Special Rapporteur regrets that trends in modern mental health legislation and clinical practices worldwide have allowed the proliferation of non-consensual measures. Coercion is widely used in mental health-care services, and there is evidence that the prevalence of coercive measures in mental health-care services is growing.22 These tendencies risk eroding trust in mental health services, damaging the image and reputation of mental health service providers and, most importantly, continue to raise serious concerns about systemic human rights violations in the field of mental health care. 49. Current mental health policies have been affected to a large extent by the asymmetry of power and biases because of the dominance of the biomedical model and biomedical 20 21 22 10 See National Health Service Health Scotland, Scotland’s mental health: Adults 2012. See Diana Rose, Users’ Voices: The Perspectives of Mental Health Service Users on Community and Hospital Care (London, Sainsbury Centre for Mental Health, 2001). See Sashidharan, S.P. and Saraceno, B., “Is psychiatry becoming more coercive?” in British Medical Journal, vol. 357 (2017), art. 2904.