This month, we interviewed Chris Underhill, founder and director of BasicNeeds, as part of our Ashoka Series. Founded in 1999, BasicNeeds seeks to improve the lives of those living with mental illness in the third world. Chris explains the workings of his innovative model of intervention that is effective and locally owned, and how it can both be replicated and is transferable. He also shares his views on social entrepreneurship, and why mental health is such a pressing issue in the third world.
Interview by Stephanie van de Werve, Communications and Marketing Manager at Aleron
Mental illness in the third world

Aleron: What is the current situation of people suffering from mental illnesses in developing countries?

Chris: At the moment, it is estimated there are around 450 million people globally suffering from mental illnesses. This includes both the first world and the developing world. Taking a sensible mean average, it would be estimated that around two-thirds of these people are in the developing world. There is a very straightforward reason for this, and that is that mental illness relates to population – the amount of people who are mentally ill with a particular illness is proportionate to the total population. Due to the fact that they contain such a large proportion of the world population, developing countries account for up to two-thirds or even three quarters of all mentally ill people.

What this means, is that the largest absolute number of mentally ill people are being treated by governments with the least resources to treat them. This results in a huge number of cases where mentally ill people receive no treatment at all. In sub-Saharan African countries this treatment gap, the gap between the amount of people requiring treatment and the amount of treatment available, stands at around 86%. In places such as Myanmar, this gap is as high as 95%. The issue is that within many of the countries we operate in, this gap does not appear to be getting any smaller.

Aleron: What makes you a pioneer in mental healthcare issues in the developing world?

Chris: I have tried to introduce a Model that makes it possible for mentally ill people in low income settings to be treated and that enables them to continue to live at home. We have taken our Model and our delivery through partners to scale at least twice. So I would say that we have created a Model, taken it to proof of concept and then gone to scale with a further scale up contemplated in the next few years.

This is an illness (or a set of illnesses) which has been around for so many years. Until relatively recently there was no reliable medical treatment or pharmaceutical treatment available. What happened before that for centuries was essentially one form of incarceration or another. In Britain the old mental institutions were called asylums and even colonies at one point in history. These were not bad words in their times, but their function was focused upon containment rather than treatment. For many years, the highest form of care was called moral welfare, meaning you contain people kindly and without being cruel to them. The issue today is that in many parts of the world not only are people receiving no treatment at all in the medical sense, but they are also being treated very badly in a human rights sense. My teams often find people who are chained up, people who are extra judiciously imprisoned by their own communities. How you deal with that if you are running a community development organisation is very important, because you still have to have the community on your side. If you simply rush in, unchain people and rush out again it is most likely that the community will re-imprison that person, so you have to bring credible treatment and an ability to negotiate with the community. You first have to negotiate with the community and work at capacity building, and it is this social as well as medical approach that is key.

The scale our operations have reached is down to the careful and wide spread of our resources. We now have independent BasicNeeds organisations in Ghana, Uganda, Tanzania, India, Kenya, and Pakistan. All of these organisations are running the model independently. In that sense the model has ‘gone viral’, which I think is important in demonstrating the benefit that the model can generate. Overall we work in these countries as well as Nepal, Sri Lanka, Laos, Vietnam and China.

Chris is a social entrepreneur, and the founder and current director of BasicNeeds. For the past 34 years, Chris has sought to improve the life of marginalised people, both in the UK and overseas. This has seen him found and direct several initiatives, including Thrive (1978) a UK-based charity working with disabled people in horticulture, Action on Disability and Development (1985), a development agency focusing upon disabled people in the third world, and BasicNeeds (1999), which works to tackle mental disorders in the third world. In 1999 he was awarded an MBE for his work with the disabled in the UK and internationally, and in 2012 he was elected as a Senior Ashoka Fellow. Chris was awarded the Skoll Award for Social Entrepreneurship in 2013 for his contribution to the field of mental health, and was again recognised in 2014 by being selected as a Schwab Foundation Social Entrepreneur of the year.

—- Follow Basic Needs on Twitter @BasicNeeds Intl or read more at basicneeds.org

BasicNeeds Model

Aleron: Could you please explain Basic Needs’ model and tell us why it differs from any other model in international development?

Chris: I developed the BasicNeeds Model for Mental Health and Development between 2000 and 2001 and a friend of mine, an Indian gentleman called DM Naidu, tested it between 2001 and 2002. It is a community development model rather than a strictly medical model. When most people think of treatment for mentally ill people, they think of medicine, doctors, psychiatrists and psychologists. Whilst of course those are all important, the fact of the matter is that in many of the countries where we work, the resources available in purely medical terms are very modest. In many of the countries we work in – Pakistan, Sri Lanka, India – there are probably many more psychiatrists from those countries serving in the US or the UK, then there are in their own countries. Therefore, if I was to propose a purely medical model – meaning a visit by a patient to a psychiatric nurse or a psychiatrist, and that’s it – it would not be feasible. It’s been proven not to work since there are not enough resources, and in any case, the lack of a social or community-based element makes its implementation hard – if not impossible. All in all we have these huge treatment gaps due to a lack of will in the areas of policy, finances, comprehensive treatment approaches and understanding of the illnesses involved.

The BasicNeeds model relies heavily upon the ability of the community to organise, hence it is a community development approach.  The model has 5 modules to it:

Module 1 – Capacity Building

This is getting people together and training them. Not only is this training on how to properly care for those with mental health issues, it is also educating people about mental illness more broadly. This means that you call people together, including mentally ill people and their families, and you then say “… we’d like to have a conversation”. You’re not calling them together in the unfamiliar and intimidating environment of a hospital or a doctors surgery, you’re calling them into their local school room or  meeting hall and allowing a two-way conversation to play out in the actual community. Patients come with their parents or with other relatives if they can, and for the first time they start to learn mental illness actually is, and of course what it is not.

Module 2 – Community Mental Health

This approach enables people to access treatment, but uniquely, it enables them to access it within the community. It is about persuading governments to provide local clinics with trained nursing staff, to do the basic recognition and diagnosis of mental illnesses. All basic recognition and diagnosis needs supervision. We have tended to use what scarce resources there are in higher level psychiatry as a supervision service, and only as a diagnosis service in the last resort for the more difficult cases. This enables the nursing and health post staff to do most of the work. That task shift from highly specialised to less specialised is true all through the Model. In the same way, within the context of capacity building, the people who are bringing everyone together are community volunteers rather than doctors or nurses; again task shifting. In this way, you start to use the resources of the whole community more effectively, as opposed to focusing on trying to secure highly specialised people who cannot be afforded.

Module 3 – Livelihoods

This is the key to the entire model, in that it is about the reintegration of people into their communities. The Livelihoods Module is divided into two distinct beneficiary parts: the first is where people start to make a productive difference to their families. This we call ‘productive work’ and could mean helping mum with the small roadside restaurant business or Dad with the weeding on the farm plot. The second part is where people actually earn money for the household.

Take an example of a man in his young 20s living in India, who has developed schizophrenia. He starts to become preoccupied, he doesn’t wash as much, he may wander in the streets. His erratic behaviour means it is the kind of illness that frightens people around him, and alienates family members. This means dealing with a significant social stigma as well as very high levels of emotion within the family.

One of the interesting things about livelihoods is that with basic diagnosis, and the onset of treatment, patients begin to feel gradually more normalised. This is the time when people start to wash again, start to make a small contribution to the household, and so on. The most effective education can be done at this point, and it is when the mentally ill person can begin to see that they can make a productive difference to their families. The countries we are discussing here have no welfare system, and so everybody really needs to do some work. If they do not work that is already a reduction in the family income. Often a carer is needed to look after the person – since the community is reluctant to allow the mentally ill person to walk freely in their own village or community unless they are supervised – and this means that yet another family member is taken out of the workforce in order to provide care for the mentally ill person.,

When you begin to get people back into rehabilitation, back into recovery, the carer is again able to go back to work, and in time the mentally ill person can also start to make a productive contribution to family life. So a lot of our impact in terms of the Model itself relates to the value that mentally ill people can contribute to their own families. Not only is this a very tangible effect of our Model, but interestingly, seeing the mentally ill individual contributing is probably one of the most effective ways of reducing stigmatisation by the community.

Modules 4 & 5 – Research and Collaboration

The final two modules are research, which is self-evident, and collaboration. A lot of our work is focused on partner development, and it is through this collaboration that a small British agency is able to reach over 600,000 people in 12 countries.

Aleron: When did the idea to help mentally ill people in developing countries arise in the first place? What was the trigger?

Chris: I have been associated with about 9 organisations as a social entrepreneur. I have actually directed 3 of them, and set up my first organisation at the age of 29. Having worked abroad for many years since the age of 21, I kept coming across mentally ill people. Having never suffered from the trepidation of speaking to mentally ill people that some do, I would go and ask them what they were doing. Often, as people do find out if they repeat this exercise, if you ask a person with a mental illness a straight question you often get a great, really interesting and lucid answer. This starts a conversation, and in my case these conversations fostered the realisation that there were very few resources dedicated to these people. In those days I thought of facilities as being medical and it was only later that I realised that a great deal more than simply the medical aspect of treatment was required.  I came to understand that even medical facilities were in short supply and that other types of rehabilitation facilities were almost non-existent. Even a very advanced African country like Ghana only has 3 hospitals in the whole country. Those hospitals are all 50km apart one from the other, so the rest of the country has much less coverage. It struck me that it must surely be really difficult if you were a mentally ill person living in the north of that country without access to even the few available facilities in the south.

Social Entrepreneurship

Aleron: Would you say BasicNeeds is a charity or NGO, or is it rather a ‘social enterprise’. How are your main sources of income influenced by this?

Chris: In Britain, BasicNeeds is registered as a charity, but we have also registered a wholly owned company. Our operations in other countries are either characterised as charities or companies, depending upon local law.

If the question is whether make enough money to fund and run the organisation from our activities or services, the answer is that we do not at the moment. But then, like any ‘normal’ entrepreneurs, we have had to prove our model worked. This was not obvious when we started. It is becoming more apparent now, due to the number of people we have involved, the degree to which people want to write about us and discuss this model and from the number of countries that are now operating the model,. In that sense it has become a social phenomenon!

Our income will always come from a mixture of funding. As we move forward there is a reasonable hypothesis that a final mix of funding will become a hybrid finance model – for development and promotion purposes you will still have philanthropic funding, but also you will start to get sensible amounts of income through fees being paid in return for services delivered. The fees are most likely to come from government. The governments with which we work are increasingly realising that for a whole range of social and cultural reasons they have largely ignored this massive illness. After all, by 2030, depression alone is going to be the largest single burden of illness in the world. In the countries where we work, there is often little policy to deal with mental illness comprehensively. That is why we have started to talk to senior policy makers and they have started to realise need to do something about it. Once they realise that, they will ‘buy’ our services. That has, in a modest way, already started to happen in some cases.

This means we are gradually becoming a facilitating service. By selling an understanding of effective action, we are enabling the most efficient use of the resources available to the state and community. Bureaucrats in the state services, whilst they may be very willing, are not necessarily the best people to understand how to animate the actual community, or how to make the most of community based organisations. Bringing these resources together is what we currently do.

Aleron: How is Ashoka supporting you practically and what has emerged for BasicNeeds from your fellowship?

Chris: I am particularly lucky because I was invited by Ashoka to join as a Senior Fellow. There are not many senior fellows in the total Ashoka community, so in a way it stands as a recognition of one’s contribution to social entrepreneurship and of working in fields which have been relatively unexplored. Being one of a handful of Senior Fellows has helped both myself and BasicNeeds attract the attention of many others interested in social enterprise. So recognition by Ashoka brings rewards simply from the wider recognition it affords.

Aleron: You have a big history of social impact behind you. Can everyone be a change-maker? Do you feel more of a social entrepreneur or a change-maker?

Chris: When I started this work, none of the terms ‘social entrepreneur’, ‘social enterprise’ or ‘change maker’ even existed. I was the director of an organisation that was doing ‘X’. In those days the word ‘charity’ did not have a pejorative feel to it. It was just the registration that you could use to do good work. So for me, labels about are pretty irrelevant, but there is no doubt that we have brought change. There are many stories from people we have helped that are testament to that. But I think people would find it very pompous if I were to go around introducing myself as a ‘change maker’!

In this particular organisation, because I had an already quite good track record of change development I was confident it would work, though I did not completely know whether these ideas of change – economic development, social development, facilitation – could be applied to the families of the mentally ill. We now know they do, and I still say the same now as I did when I started; mental illness, in the most part, is something that can be managed. Not always cured, but managed, and it is a huge shame if it is not, because people’s lives can be destroyed. The quality of life of many people around them is also ruined, sometimes very seriously. So for me, it is really about those people.

Ashoka is a non-profit organization dedicated to finding and fostering social entrepreneurs worldwide. Ashoka is the largest network of social entrepreneurs worldwide, with nearly 3,000 Ashoka Fellows in 70 countries putting their system changing ideas into practice on a global scale.
Founded by Bill Drayton in 1980, Ashoka has provided start-up financing, professional support services, and connections to a global network across the business and social sectors, and a platform for people dedicated to changing the world. Ashoka launched the field of social entrepreneurship and has activated multi-sector partners across the world who increasingly look to entrepreneurial talent and new ideas to solve social problems.