Given the limitations of the existing model of community care for mental disorders in developing countries, Jacob (Reference Jacob2001) has tried to construct another model and has focused on some of the constituent elements of such a model. Although Jacob insists on a potentially innovative approach to the provision of mental health services in developing countries, the framework within which to take forward the debate regarding community care fails to analyse in depth the sociopolitical and economic contexts in which community care is constructed. Owing to the strong emphasis placed upon discriminatory social and political structures, an analysis of what it is to be mentally ill, and the sociological and psychological implications of this, has largely been ignored.

I agree with Jacob that cooperation between governments and non-governmental organisations (NGOs) in providing community care will help in implementing health care policies. However, by their very nature, NGOs are heterogeneous and vary from large agencies operating in many countries (e.g. Oxfam, Save the Children Fund) to very small organisations operating at village level. Despite the growth of NGO activity in the past decade, there remain questions regarding their effectiveness in achieving their stated objectives (Reference NyoniNyoni, 1987). Evaluation of an NGO's effectiveness can become something of a propaganda exercise, aimed more at impressing donor agencies than at a critical analysis of the NGO's activities. A related issue concerns the mixed accountabilities of NGOs — ‘downwards’ to their collaborating partners and ‘upwards’ to their donor agencies. These issues result in difficulties of monitoring and enforcement (Reference BrettBrett, 1993).

We know that the lives of individuals with mental illnesses around the world are usually limited far more by prevailing social, cultural and economic constraints than by their illnesses. If this is the case, then the issues related to community care for people with mental disorders move from those of health to those of human rights. Their lives are hard indeed. Mental health professionals can help to change this state of affairs. Whether the issue is community care in urban London or in rural India, professionals who work on mental health issues must extend their perspective beyond the bounds of policies and programmes if they are to help make a meaningful difference in the lives of those they serve.

This does not mean that policies and programmes are not needed — they clearly are. But the tendency to implement readymade models could easily miss the needs of the target groups. Community care programmes have to be tied to broader social and economic policies and programmes. Mental health professionals can contribute their expertise to this process and work in conjunction with these people and their families to strengthen their voices in the arena of human rights.