Narasimhan et al. Int J Ment Health Syst (2019) 13:54 https://doi.org/10.1186/s13033-019-0313-8 International Journal of Mental Health Systems

CASE STUDY Open Access Responsive mental health systems to address the poverty, homelessness and mental illness nexus: The Banyan experience from India Lakshmi Narasimhan1,2,3* , Vandana Gopikumar1,2,4, Vaishnavi Jayakumar1,2, Joske Bunders3 and Barbara Regeer3

Abstract Background: Mental health has gained prominence as a global public health priority. However, a substantial treat- ment gap persists in many low- and middle-income countries. Within this scenario, the nexus between homelessness, poverty and mental illness represents a particularly complex issue. This article presents the experience of The Banyan, a 25 years old non-proft organisation providing mental health care to people living in poverty in Tamil Nadu, India. Case presentation: The case study describes the evolution of The Banyan using a timeline narrative. By applying an action learning framework, the organisation’s evolution through four lifecycles, strategy and the key elements under- lying mental health system responses are identifed and presented. ‘User centred’ and ‘service integration’ emerge as the main dimensions of The Banyan’s responsive health system. Relating to these two attributes, a typology of services is derived, indicating the responsiveness of mental health systems in addressing complex problems. The role of the organisational culture and the expressed values during the transition is considered. Conclusions: The case study serves as an example of how responsive mental health systems may be constructed with both a user centred and a service integration focus. Keywords: Homelessness, Mental health, Health systems, User centred, Service development, Transition management

Background health systems defcits, stigma and multidimensional Mental health has gained prominence as a global pub- poverty persist and prevent access to care. lic health priority in the recent years. Mental disorders India is home to an estimated 150 million people with account for nearly 13% of the global disease burden mental illness [4], but only 10% of people with com- according to one estimate [1], and are responsible for mon mental disorders and only 40–50% of people with 37% of healthy years lost due to disease among non-com- schizophrenia receive care [5]. Provision of mental health municable diseases [2]. Despite the development of evi- care in India, as in many other LMICs, faces a number dence-based interventions, 75–90% people with mental of serious challenges. Mental health services are grossly illness in low- and medium-income countries (LMICs) inadequate [6] and tend to approach mental illness from are not in treatment [3]. Systemic barriers in LMICs such a disease perspective [7], ignoring complex economic as lack of sufcient budgets and human resources, public and social problems that contribute to wellbeing. In this context, the nexus between mental illness, poverty and homelessness represents a particularly persistent and *Correspondence: [email protected] complex problem [8]. Homelessness, poverty and mental 1 The Banyan, 6th Main Road, Mogappair West, Chennai, India Full list of author information is available at the end of the article ill-health are recursively related phenomena explained by

© The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat​iveco​mmons​.org/licen​ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Narasimhan et al. Int J Ment Health Syst (2019) 13:54 Page 2 of 10

both social causation and social drift [9]—people experi- reintegration and aftercare interventions that aim to sup- encing social and economic adversities have higher prev- port users in fnding pathways back to their families and alence of and risks for mental ill-health [10–14], while communities of choice. Te Emergency Care and Recov- those with mental health issues lapse into downward ery Centre (ECRC) has been accessed by 1942 home- trajectories of poverty and homelessness [15–17]. In the less women with mental illness, of whom 1478 (nearly Indian context, with sizeable scarcity of resources and three-quarters) have journeyed successfully back to their services for mental health, homeless people with mental families all over India. About 40% of those in residential illness have few alternatives besides continuing on the care participate in work, full-time or part time employ- streets or institutionalisation in mental health facilities ment or social enterprises housed on campus. A 2010 [18] or beggar’s homes [19]. study of a sample of women reintegrated from ECRC Health system reforms to address the treatment gap found that 20% were in paid employment and 61% were often focus on increasing availability of services using engaged in household occupational roles [21]. Te same fnancial and human resources investments. While such study found that 73.3% did not experience homelessness reforms may increase capacity of services, the fundamen- again and 84.4% remained in continued care through out- tal nature of the health system may remain unaltered. patient services. Te ECRC approach has been adopted Given the complexity of the needs of the people who face by the Government of Tamil Nadu. Five centres fnanced the double jeopardy of homelessness and mental illness, by the state are collaboratively run in District Hospitals. more fundamental change is needed. Some civil society Te reintegration component has been replicated col- initiatives such as Ashadeep (Guwahati), Iswar Sankalp laboratively with the Government of Kerala across state- (Kolkata), Koshish (Mumbai), and state-run institutions run psychiatric hospitals to help reunite long-stay clients such as the Hospital for Mental Health (Ahmedabad) with their families and access aftercare services. and the Institute for Health and Behavioural Sciences Inclusive Living Options ofer choice-based housing (Delhi) have developed services to address the needs of (congregate or non-congregate) with personalised sup- homeless people with mental illness in India. Codifying portive services (across work, socialisation, economic such local responses and experiences can help generate transactions, daily living and leisure), particularly for socially robust knowledge and advance evidence-based those who are unable to return to their families or live practice and policy [20]. Te primary aim of this article independently and are at risk of long-term institution- is to understand and describe the development of men- alisation in psychiatric facilities. About 200 people with tal health system responses that may address needs of mental illness with long-term care needs ranging from people with mental illness living in poverty and home- low to high disability levels are living in homes as part lessness. To do this, the article presents a case study of of formed families in rural and urban neighbourhoods the evolution of Te Banyan, a non-proft organisation with onsite support and case management at Clustered providing mental health care in India and refects on Group Homes (CGH) and Home Again (HA). A pro- implications for the nature of mental health systems. Te spective 18-month evaluation between 2014 and 2016 of secondary aim is to understand the organisational culture 53 participants of HA with matched controls in Care as that promotes mental health system responses as a basis Usual (CAU), the institutional facility, found a signifcant for scaling up such systems. efect on community integration, which increased among participants in HA. Disability reduced signifcantly with Case presentation time among participants of HA [22]. Similar results Te Banyan provides comprehensive mental health ser- were found in a prospective evaluation using two-group vices in institutional and community settings for people design of 113 participants assigned to HA compared experiencing poverty and homelessness in the states of with the matched controls in CAU across sites in Tamil Tamil Nadu, Kerala and Maharashtra. Starting in 1993 Nadu, Assam and Kerala. Te intervention is being rep- with a crisis intervention and rehabilitation centre for licated with the Governments of Kerala and Maharashtra homeless women with mental illness in the city of Chen- to address long-term institutionalisation in state mental nai, Te Banyan’s continuum of care currently has three hospitals. major services: Emergency Care and Recovery Services, NALAM (Tamil for wellness) is a community mental Inclusive Living Options and NALAM: Community health programme that ofers packages of care delivered Mental Health Programme. by grassroots mobilisers supported through clinics co- Te Emergency Care and Recovery Services are pri- located with primary health centres or community cen- marily ofered at a 120-bed facility for homeless women tres across rural and urban geographies. About 10,000 with mental illness in the city of Chennai. Te services people have accessed proximal, comprehensive and include crisis intervention, multi-disciplinary care, personalised mental health care through NALAM. Te Narasimhan et al. Int J Ment Health Syst (2019) 13:54 Page 3 of 10

services include outpatient and inpatient clinical care, learning [23] in which knowledge is co-created by vari- home-based services, social entitlement facilitation, live- ous participants who act and refect on real world issues. lihood interventions, education and housing support, Tis was reviewed independently by VG and JB, who sent support groups and mental health promotion. Data from feedback to LN, who then incorporated changes that a cross-sectional survey of 346 women who accessed were concordant and moderated discussions for changes outpatient services between September 2015–December that were discordant. Tis process was repeated until 2015 show that half perform independent occupational the four authors (VG, LN, JB and BR) agreed on the fnal roles and a quarter of them are in paid employment. Te output. Interpreter triangulation was facilitated through Banyan has recently entered a collaboration with the a recursive process of organising data individually and Government of Tamil Nadu in two districts to strengthen collectively refecting and discussing the data. Te four the state-run District Mental Health Programme domains in action refection learning processes—plan- (DMHP) using the community engagement components ning, action, observation, refection [24]—were used to of NALAM. construct an analysis matrix: In order to address defcits in human resources, Te Banyan Academy of Leadership in Mental Health • Planning: elements of narrative that constitute a (BALM) engages in education and research. BALM ofers strategic direction towards achieving organisational masters level programmes in Social Work and Applied vision; Psychology (with specialisations in clinical psychology • Action: elements of narrative that involve activities to and counselling psychology) and a Diploma in Commu- execute the plan; nity Mental Health. Since inception, 229 students have • Observation: elements of narrative relating to what graduated from the masters programmes and 116 have the organisation experienced following implementa- completed the Diploma. About three-quarters have con- tion of planning; and tinued to engage in the mental health sector, majorly in • Refection: narrative elements that express learning employment, with some in higher studies. as result of the execution experience and the meas- urement of progress in congruence with the organi- Methods sational vision. For this case study, the authors retrospectively and quali- tatively examine evolution of Te Banyan’s responses in the mental health sector. Two qualitative methods were used: a timeline narrative of the organisation and analy- Lifecycles sis using action learning framework. A timeline narra- Organisation of Te Banyan’s narrative into the four tive was constructed based on data from key informants, domains of planning, action, observation and refection annual reports and evaluation reports. Insights from four revealed four distinct lifecycles into which the organic key-informants were collected and integrated. Two of the evolution of Te Banyan may be categorised, each one four key informants were service users of Te Banyan with a plan originating from the refections of the previ- with over two decades of engagement. Both women were ous lifecycle. Te Banyan started as a shelter service for 45 years old at the time of the interview and were work- homeless women with mental illness. Te experiences ing at BALM. Two others were staf, one man and one of the co-founders in the months preceding the estab- woman, currently in senior management positions. Te lishment, included public apathy to visible distress of a former has been with the organisation since inception woman ‘in the middle of heavy trafc’ on a busy road in and the latter since 2002. Tey were aged 45 and 29 years Chennai, the lack of any kind of facilities, and repeated respectively at the time of the interview. encounters with many such women in distress. Te evolution of Te Banyan has been described in Te shelter facility started to provide a safe space for several documents such as annual reports and evalua- homeless women with mental illness and developed tion studies. Twenty annual reports (years 1993–2014) into a transit recovery space. With recovery of users and and three evaluation studies were examined retrospec- their expressed needs of living with family, Te Banyan tively and qualitatively, covering critical changes and key began facilitating reunion with families (Lifecycle 1). Te elements of organisational strategy, in order to develop positive response of many families and communities in a conceptual framework for mental health system welcoming back these women altered the organisation’s responses in the context of complex problems. A timeline understanding of what had led to homelessness. Te narrative was constructed by LN and VG. Next, LN and organisation also recognised that the magnitude of issue BR coded the timeline narrative separately and analysed was far greater than initially anticipated; and that conti- the coded data together using models of action refection nuity of care post reintegration was critical. Narasimhan et al. Int J Ment Health Syst (2019) 13:54 Page 4 of 10

From 1996 onwards, Te Banyan expanded capacity by stronger development agenda within Te Banyan, involv- constructing new premises and began to ofer multiple ing a comprehensive social care system of welfare enti- aftercare options for those who had left the shelter (Life- tlements and interventions targeting well-being. Quality cycle 2). Reintegration became systematic and included assurance systems were introduced within institutional options for self-discharge, employment, living in group care, focusing on privacy and dignity during bathing, and homes and referrals to non-mental health institutions. the availability of a minimum level of assets such as ftted, As numbers continued to increase, Te Banyan realised coordinated clothes. the importance of putting the needs of the constitu- Te organisation further integrated a well-being ency on the agendas of local and national governments. approach towards mental health into its community Tis involved an increasing emphasis on the role of the mental health programs by initiating the NALAM (Tamil state and rights of homeless persons. In the provision of for ‘wellness’) project. Te project utilises village level aftercare, Te Banyan began to understand the difcul- wellness mobilisers to deliver a range of interventions ties of recovery in families living in poverty. Local care, from counselling to social welfare facilitation to pro- expressed as a need by users, was hypothesised by a third mote outcomes in socio-economic spheres as a preven- party evaluation [25] as being important to maintaining tive strategy towards better mental health. Te Banyan recovery. In addition to challenges in providing aftercare, also investigated alternate service contact options for Te Banyan experienced problems with institutional homeless persons with open shelters and street engage- care: many people with long term needs were unable to ment in partnership with the Corporation of Chennai. exit the system and large communal spaces were not con- Trough this initiative the organisation has been able to ducive to providing quality care. ofer fexible and user-initiated access options for home- During 2004–2012, user demands for alternate living less persons. Based on the NALAM approach, an active spaces for those who could not return to their families engagement with the community in vicinity, Dooming led Te Banyan to develop shared housing and commu- Kuppam, through life skills, skills development and other nity living options (Lifecycle 3). Te need for continuity social interventions have been incorporated as a key of care led to piloting of socioeconomic interventions component of this project. (disability allowances, employment, housing support). In addition, driven by the success of independent liv- Trough this engagement in social care, Te Banyan ing through shared housing in the villages and its impact began to develop a deeper understanding of the perpetu- on the lives of women who were once homeless, the ating nature of inequities, including poverty, gender and organisation extended this approach towards address- old age. Local care did not always translate to benefts on ing the needs of those who require higher support. Tis the equity front, with poverty continually placing persons approach called Home Again, involves the facilitation with mental illness at the risk of downward social drift of housing with graded levels of support, with a focus and homelessness. Te Banyan also learnt from user eval- on facilitating socio-economic-political participation of uations that positive outcomes are rooted in experiencing users in communities. a better life. Tis led Te Banyan to link care adherence Te organisation recognised that there was a paucity in to benefts that may mitigate socio-economic distress. human resources aligned with the ethos and skills neces- Te Banyan also began to collaborate with other stake- sary to deliver interventions such as the ECRC, NALAM holders, such as the state mental health facility and other and Home Again. Terefore, masters level courses and NGOs, to replicate its recovery and reintegration model. diploma programmes were developed to cultivate critical Te challenges of providing institutional care rooted in perspectives and values by ofering opportunities to learn an ethos of user self-determination became more evi- by observing and doing in the real world. dent: while there needed to be protocols for minimum Table 1 provides a summary of system level transitions services and processes, the key challenge was privileg- in Te Banyan’s mental health system. Action learning ing user needs and rights among human resources. Tis and the four domains of plan, act, observe, refect consti- led to the identifcation of human resources defcits in tute the main basis of the analysis in this discussion. Te the mental health sector, not just in terms of numbers analysis matrix has been condensed into the table above but also the lack of appropriate core values, leadership to provide a summary of organisation level transitions in and multi-disciplinary intervention skills. Refections on Te Banyan’s mental health system. Narrative elements these developments led to changes in service integration from plan and action have been combined and summa- during Lifecycle 4 from 2012 onwards, placing greater rised under row labelled ‘Focus’; while those pertaining emphasis on recovery in the context of poverty. Greater to ‘observation’ and ‘refection’ are summarised under understanding of the complex causal pathways to home- row labelled ‘Reasons for focus’ in Table 1. ‘Organisation lessness and of user expectations led to the adoption of a level evolution’ based on the strategic shifts in ‘Focus’ of Narasimhan et al. Int J Ment Health Syst (2019) 13:54 Page 5 of 10 approaches in community and approaches on with a focus institutional care identity/personalwell-being: growth/ self-determination/meaning in life theory integrate to and resources feld practice in the relationship between poverty, between poverty, in the relationship and care mental health, access to outcomes health services integration operating protocols standard to of issue dynamic nature given with psychosocial concerns living with psychosocial in poverty and homelessness in low settings resource mental health sector - fed local governments, institutions, community and unfederated erated Other Governments, institutions, Hospitals, civil society organisations, General Public Media, Corporates, Lifecycle 4 Lifecycle 2012–present Development of reconstructive Development of reconstructive Building capacities among human Micro and complex issues: non-linearity mental to focus development Need for values scaling as opposed Ethos/Core Persons, families and communities Persons, and in development Human resources Academic community, international community, Academic - munity and stakeholder expansion, and advocacy research in care hypothesised to stem from from stem to hypothesised in care vs absence defcits in presence community mental health as a means of scaling of protocols up families living in poverty and home lessness in urban and rural areas organisations, hospitals, media, hospitals, organisations, general public corporates, Lifecycle 3 Lifecycle 2004–2012 Mental health services in the com - Lack of access to care and continuity care Lack of access to and dissemination Model formulation Persons with mental illness and their Persons Government, Other civil society - ening capacity, content and quality content ening capacity, of responses complexity; Infrastructure develop of systems ment with strengthening efciency as for perceived of care solution and their families communities pitals, media, corporates, general media, corporates, pitals, government public, Lifecycle 2 Lifecycle 1996–2003 Institutional- strength development: Scale of issue in quantity as as well Homeless women with mental illness Homeless women Other hos - civil society organisations, women with mental illness: crisis women reintegration, intervention, shelter, after-care address deprivation and violence address with homeless women faced by mental illness philanthropists, social clubs philanthropists, Lifecycle 1 Lifecycle 1993–1996 Humanistic response to homeless to Humanistic response Lack of adequate responses to to responses Lack of adequate Homeless women with mental illness Homeless women Hospitals, media, general public, media, general public, Hospitals, Transitions in The Banyan’s strategy Banyan’s in The Transitions refection) 1 Table Dimensions of Strategy Focus (planning and action) Focus Reasons for focus (observation focus Reasons and for Description of constituency Description of stakeholder system Narasimhan et al. Int J Ment Health Syst (2019) 13:54 Page 6 of 10

Te Banyan have been demarcated into four lifecycles the centre in defning responses; and ‘service integration’, represented across the columns. namely instituting appropriate, multiple responses at an Te analysis shows that over two decades of work in organisational level. To understand how these develop- homelessness and mental health, Te Banyan’s focus has ments and organisational health systems can be scaled developed from crisis intervention for homeless women up, we consider the organisational culture driving this with mental illness to an integrated service approach, process of development. including a wide variety of responses to clients’ psycho- logical, fnancial, cultural and social well-being. Indica- Organisational culture and values tive of the change from crisis intervention to prevention Organisational culture is like an iceberg, only a small part to supporting well-being is the growing constituency of it is visible or manifest [27]. Expressed values represent that is considered service-user of Te Banyan’s, including the key aspect of manifest culture [27] and, for that rea- communities in low-resource settings at large. son, values consistently apparent throughout the organi- In parallel, and as a response to the need for develop- sation’s evolution represent the focus of this analysis of ing human resources in new directions, the stakeholder organisational culture. system that developed around Te Banyan expanded to Although there have been considerable changes in Te include non-traditional partnerships that are instrumen- Banyan’s strategic focus since 1993, the expressed val- tal to Te Banyan’s success. During Te Banyan’s evolu- ues have remained unchanged: commitment to the well- tion, it became evident that focusing on one element being of people, drive to understand the needs of clients, of the problem was not enough: clients are caught in a acceptance of the complexity of the reality of clients, and multidimensional trap that needs to be approached in a willingness to reconsider the identity of the organisation. tailor-made, user-centred way. Both micro and organisa- Tese values have been built into the organisational cul- tion level transitions in Te Banyan have been based on ture through a number of processes: increasing understanding of user demands and needs. Clients have evolved from service users to participants • listening to the needs of clients during an ongoing to owners. For example, homeless women with mental dialogue in which all staf members participate;1 illness who once used Te Banyan’s shelter services now • maintaining high staf morale under extremely dif- work as mental health ‘change agents’ in their communi- fcult circumstance by articulating, sharing and cel- ties. Initially prioritising user self-determination (Lifecy- ebrating achievements, large and small; cle 1), the organisation engaged in an ongoing dialogue • achieving synergy between ambitions, competences with its service users to gauge their experiences, needs and activities by actively dialoguing with all network and outcome defnitions. Tis process of dialogue for co- partners and staf members; creating knowledge served as the basis for formulating • combining in-depth understanding of the problem systemic responses. As a consequence of the user centred with the bigger picture by stimulating continuous focus, Te Banyan worked towards service integration in refection among stakeholders terms of quantitatively enhancing service diversity and levels, and qualitatively enhancing levels of integration Tese values help to promote an organisational culture within the delivery system. Responses to emerging user that is anchored in an action learning approach, which is input, such as a trip to reunite with family (Lifecycle 1 centred on a continuous dialogue with clients leading to to 2) and alleviating fnancial distress (Lifecycle 2 to 3), innovation in practices, services and structures. While were institutionalised as systematic mechanisms, a pro- the transitions in Te Banyan’s evolution emerge from cess that increased comprehensiveness of both horizontal one lifecycle to another, they were preceded by a pro- and vertical service oferings. Dialogue with users helped cess of co-developing these services at a micro level with Te Banyan understand that intersecting infuences of service users. Tis dynamic nature of change driven by social disadvantage and trauma on mental health, rather the constituency is a key feature, wherein responses are than untreated symptoms, are implicated in the urban ongoing leading up to organisation level change, rather reality of homelessness among those with mental illness than in discrete blocks of planning, acting and evaluating [26]. Tis informed the organisation’s evolution from (Fig. 1). crisis intervention and shelter in family-like settings to integrated health and social care services on a continuum that expanded to include community mental health and community living options. 1 Te Banyan conducts an annual service user audit. Tere are meetings of Tus, two key attributes emerge from the analysis of user-carer groups and an external human rights committee monthly that Te Banyan’s evolution: ‘user centred’, placing the user at serve to record and incorporate the voice of users into service design and delivery. Narasimhan et al. Int J Ment Health Syst (2019) 13:54 Page 7 of 10

Approach Continuous dialogue about needs Innovate on the basis of needs

User Centered Action Learning Spiral Integrated Services Plan Plan Plan

Reflect Act Reflect Act Reflect Act

Observe Observe Observe

Values Commitment to wellbeing Drive to understand needs of clients Acceptance of complexity of client realities Willingness to adapt organisational identity

Fig. 1 Value driven Action Learning Spiral (Authors)

Several challenges accompany the evolution of Te long-stay options were developed. Second, difusion of Banyan. Tese include: the paucity of resources, provi- values and new practices organisation wide (across pro- sion of aftercare to distributed geographies with scare grammes and staf) may call for continuous processes local mental health services, disconnect between health of immersive-learning and supervision, beyond didactic and social welfare systems, and the exclusion of men- dissemination and trainings. tal health and homelessness from a wide array of social entitlements. From a systems development perspective, two impor- Discussion tant lessons may inform initiatives in mental health that Typology of mental health system responses may take a similar path. First, collaborative refections Based on the dimensions ‘service integration’ and ‘user among users and staf that combine quantitative indica- centred’ emerging from analysis of Te Banyan’s mental tors along with qualitative lived experience and practice health system, we introduce a typology of mental health narratives can assist in the process of evolving systems. system responses (Fig. 2) which may be used as a heuris- Te Banyan’s data have been organised to feed into quan- tic tool to understand diferences between types of men- tifable indicators tracked by a monitoring and evalua- tal health services. tion system only in the last 6 years, whereas these may Te typology presents four ideal-types, which by def- have been useful to inform strategies from inception. nition, do not correspond one-on-one to empirically For instance, in the initial years, the institutional facility observed phenomena. Rather, an ideal-type, as coined by grew exponentially in an attempt to cater to the unmet Max Weber [28] represents an analytical construct based needs of homeless women with mental illness. Dur- on specifcally accentuated characteristics of a concrete ing this period, the proportion of long-stay users in the phenomenon. Tey are used to understand, rather than facility grew, duration of stay before discharge increased represent social reality. At the same time, exemplars can and maintaining quality standards became challenging. be identifed—phenomena that serve as an exceptional ECRC’s bed-strength was subsequently fxed at 120 and example of an analytical construct [29]. Narasimhan et al. Int J Ment Health Syst (2019) 13:54 Page 8 of 10

High

y axis:Service Integration

Low User centred High Service Integration High User centred High Service Integration Example: Multidisciplinary Example: Adaptive mental specialist and health system tertiary mental health hospital

x axis:User-centered Low High

Low User centred High User centred Low Service Integration Low Service Integration Example: Periodic standalone Example: Free meals psychiatric camps distributed on the streets for homeless people

Low Fig. 2 Typology of mental health system responses

In this typology, the x-axis represents the degree to as psychiatry, psychology, social work and occupational which services in a health system are ‘user centred’, therapy are involved in the process of delivering care, while the y-axis represents the degree to which services but such coordinated eforts may be driven by the expert in a health system demonstrates ‘service integration’. perspectives of what user needs are. In such an instance, Responses of agents (individuals or organisations) within despite sophistication, services may continue to not the health system may be highly user centred, but may appropriately address user needs. Unidimensional inter- not be integrated in a systematic manner. An example ventions that are again not changing with user input, is a response that involves distribution of free meals to such as periodic standalone psychiatric camps to screen, homeless persons on the streets. Some initiatives involve diagnose and dispense medication with no grassroots delivery of repackaged leftover food (from restaurants follow up mechanism, are another type of health system and other such establishments) or freshly cooked food response. Such responses if fulflling an aspect of user by volunteers or staf to homeless people. Tey address needs may potentially lead to impact that are restricted a vital need, particularly for homeless people with men- to shorter cycles, while failing to build these into long tal illness, some of whom may not access soup kitch- term gains. Finally, highly user centred and service inte- ens or other such food sources. As a standalone service, grated responses are those that adapt to emerging needs while on a case-to-case basis other emerging needs such and priorities, change direction if needed and swiftly as health may be met, there is no process at a systems adopt innovative services. level, which may lead to limited scoping and outreach. On the other hand, one may also have highly integrated Scaling up: from organisational level to the health system services, which are constructed without placing the user History shows the health system reform through top- at the centre. An example may be multidisciplinary spe- down measures has been largely inefective while bot- cialist tertiary mental health hospital with no processes tom-up initiatives have often failed to scale up [30]. It for service user participation. Several disciplines such is increasingly recognised that components of health Narasimhan et al. Int J Ment Health Syst (2019) 13:54 Page 9 of 10

systems should be perceived as interlinked and that between various stakeholders while consistently refect- they are a product of the social, economic, cultural and ing on the bigger picture and pushing boundaries for political context in which they are developed [31]. Tak- what is aspired for change. Radical learning, that can ing such a complex adaptive system perspective to health alter the course of unresolved, complex and persistent systems has implications for health system reform. New problems, is made possible through a collaborative approaches for system change have been developed and shared space for continuous refection and action. Ser- tested in the emerging research felds of system innova- vice delivery frameworks may require mechanisms that tion [32, 33] and transition theory [34], originally devel- can continually translate the same into mental health oped in the felds of sustainable agriculture and energy, formulations for practice. Tis may call for bottom up and more recently applied in the feld of health care health systems, unique to the constituency they serve, and health system reform [30]. It poses that the actions with core value frameworks serving as the replicable of agents at the micro level of a system are governed by components of such systems. laws, regulations, cultural values, beliefs of the meso level Acknowledgements of a system, also referred to as the regime. It explains We thank Ashok Kumar and Swapna Krishnakumar, Jyoti and Mary Chitra why new initiatives at micro level often fail to scale up to for their contributions to The Banyan’s journey and their insights that made this article possible. We acknowledge Dr. KV Kishore Kumar, Director of The reform the system [35]; new practices are not adopted, or Banyan, for his technical inputs that shaped the organisation’s learning. We even counteracted, by incumbent institutions at regime acknowledge the valuable support of governing boards of The Banyan and level. BALM, donors, staf and volunteers. We thank Sarah Cummings for her editing. Increasingly it is argued that adaptive capacity is essen- Authors’ contributions tial not only for the organisations that are part of a health LN, BR and VG drafted the manuscript. VJ and JB provided additional inputs system, but also for the health system as a whole [30, that were incorporated in the fnal manuscript. All authors read and approved the fnal manuscript. 31]. It is for instance argued that health systems should not only be seen in terms of its components (the peo- Availability of data and materials ple, institutions and resources that deliver health care Data and materials will be shared upon request to Lakshmi Narasimhan, The Banyan, India. services to meet the health needs of target populations) and their interrelationships, but also in terms of their Competing interests ‘responsiveness to legitimate expectations’ [36]. Besides The authors declare that they have no competing interests. responding to users’ expectations, crossing boundaries Author details (for example, between health and social welfare minis- 1 The Banyan, 6th Main Road, Mogappair West, Chennai, India. 2 The Banyan tries, local and international organisations) is seen as a Academy of Leadership in Mental Health, Chennai, India. 3 Athena Institute for Research on Innovation and Communication in Health and Life Sciences, key attribute of mental health systems [31]. Tese schol- Faculty of Science, VU University Amsterdam, Amsterdam, The Netherlands. ars perceive health system reform beyond the develop- 4 School of Social Work, Tata Institute of Social Sciences, Mumbai, India. ment and difusion of new interventions and increasing Received: 25 September 2018 Accepted: 5 August 2019 human capacity and instead argue for a move towards an adaptive (mental) health system that listens to needs (user centred) and responds by innovating practices through crossing boundaries and integrating services. References 1. Vigo D, Thornicroft G, Atun R. Estimating the true global burden of men- Conclusions tal illness. Lancet Psychiatry. 2016;3:171–8. https​://doi.org/10.1016/S2215​ -0366(15)00505​-2. Tis analysis of Te Banyan’s evolution suggests a 2. Bloom DE, Cafero E, Jané-Llopis E, Abrahams-Gessel S, Reddy Bloom dynamic, responsive and system innovation approach L, Fathima S, et al. The global economic burden of noncommunicable diseases. 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