Health in Action Integrating Mental Health and Development: A Case Study of the BasicNeeds Model in

Shoba Raja1*, Chris Underhill2, Padam Shrestha3, Uma Sunder1, Saju Mannarath1, Sarah Kippen Wood4, Vikram Patel5,6 1 BasicNeeds Policy and Practice Directorate, Bangalore, , 2 BasicNeeds UK, Leamington Spa, United Kingdom, 3 Livelihoods Education and Development Society (LEADS), Pokhara, Nepal, 4 BasicNeeds Policy and Practice Directorate, Oakland, California, United States of America, 5 Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom, 6 Sangath, Goa, India

This case study is part of the PLoS resource settings [8,9]; and the BasicNeeds This paper will focus on a description of Medicine series on Global Mental Model offers a feasible method of integrat- one particular MHD program in Nepal. Health Practice. ing mental health into existing community- The Nepal program was chosen because based interventions [10]. this allows highlighting operations in a BasicNeeds has witnessed exponential fragile state where the government is un- Mental Health and growth in response to requests for MHD pro- able to deliver even the most basic services, Development grammes. In 2011, BasicNeeds operated particularly in remote regions [12]. Nepal is MHD programmes in a total of 98 districts also the first country where BasicNeeds has People who live in conditions of social in 11 countries (, , , not set up a country office but operates disadvantage are at greater risk of develop- , India, , Nepal, Lao PDR, through a direct partnership with an ing mental illness [1]. Access to treatment in and , with new programmes being independent local nongovernmental orga- low- and middle-income countries (LMICs) initiated in and the United Kingdom), nization, with expertise in community- is limited and can be expensive [2]. Stigma working with 55 local partners, reaching based rehabilitation (CBR) and related makes it difficult to secure already limited 39,518 affected individuals. A major challenge training, called Livelihoods Education and employment and education opportunities has been sustaining existing programmes Development Society (LEADS)—an oper- [3]. While a mental health treatment gap while adding new ones. After extensive con- ational prototype for future franchisees. has been widely acknowledged, less atten- sultations, BasicNeeds planned further scale tion has been paid to addressing the poverty up through a social franchise of the MHD MHD in Nepal—A Case Study gap, which often accompanies mental illness model, i.e., a commercial franchising [4]. The recent World Health Organization approach to replicate and share organization- Nepal is a Himalayan country, sand- (WHO) report on mental health and al models for greater social impact [11]. wiched between China and India, with a development concluded that people with mental health conditions met all the criteria Citation: Raja S, Underhill C, Shrestha P, Sunder U, Mannarath S, et al. (2012) Integrating Mental Health and for vulnerability and merit targeting by Development: A Case Study of the BasicNeeds Model in Nepal. PLoS Med 9(7): e1001261. doi:10.1371/ development strategies and plans [5]. journal.pmed.1001261 BasicNeeds was founded in 2000 and Published July 10, 2012 developed its community-based integrated Copyright: ß 2012 Raja et al. This is an open-access article distributed under the terms of the Creative Mental Health and Development (MHD) Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, model, inspired by development theory, provided the original author and source are credited. which emphasizes user empowerment and Funding: DFID, UK, provided funding for implementing the Mental Health and Development Model in Nepal. Vikram Patel is supported by a Wellcome Trust Senior Research Fellowship in Clinical Science. The funders had community development, as well as streng- no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. thening health systems and influencing Competing Interests: SR, US, SM, and SKW are employed by BasicNeeds, a mental health and development policy [6,7]. Figure 1 shows each compo- organization. CU founded BasicNeeds. At the BasicNeeds Nepal programme, their partners in Nepal (LEADS) nent of the MHD model. contacted a Nepalese pharma company—Asian Pharmaceutical Company—for assistance in providing In practice, the five modules of the MHD medicines to the Users who access services in the programme’s operational districts of Baglung and Myagdi in the Western region. As a result, the company agreed to provide free medicines for up to 200 users attending model work in conjunction to address the the MH camps organised by LEADS at the district hospitals. They have so far supplied twice. Discussions are treatment, capabilities, and opportunities currently going on for their continued help and for them to supply directly to the two district hospitals in gaps experienced by affected individuals. future. This provision of medicines is done without any formal contractual arrangement with LEADS (or BasicNeeds) and there is no direct financial association between our organizations and Asian Pharmaceutical Evidence suggests that community-based Company. In a nutshell, the sum total of the association is the provision of free medicines for 200 patients (and models that integrate health care and social possibly more in the future). PS is employed by LEADS, a non-profit organisation which provides medical interventions can have a positive impact on treatment and other support services to individuals with mental illness. VP is a guest editor of the Global Mental Health Practice Series and was involved in the selection of commissions, including this particular paper, clinical outcomes and social and economic but he was not involved in the peer review or editorial decision making about this article. functioning for affected individuals in low- Abbreviations: CBW, community-based worker; FCHV, female community health volunteer; HMIS, health management information system; LEADS, Livelihoods Education and Development Society; LMIC, low- and middle-income country; MHC, Mental Health Camps; MHD, Mental Health and Development; PPP, purchasing The Health in Action section is a forum for power parity; SHG, self-help group; WHO, World Health Organization; WRH, Western regional hospital individuals or organizations to highlight their * E-mail: [email protected] innovative approaches to a particular health prob- lem. Provenance: Commissioned; externally peer reviewed.

PLoS Medicine | www.plosmedicine.org 1 July 2012 | Volume 9 | Issue 7 | e1001261 Summary Points Development, UK, is a 4-year programme (May 2010–March 2014) operating in N The BasicNeeds model of Mental Health and Development (MHD) emphasizes Baglung and Myagdi districts, with popu- user empowerment, community development, strengthening of health lations of 270,009 and 113,731, respec- systems, and policy influencing. tively. The majority depend on agriculture for their livelihood. A baseline situational N The MHD model works in partnership with governments to provide the ‘‘great analysis revealed the absence of any push’’ that is required to set up services where mental health and development has not been a priority. government mental health services and an absence of mental health trained hu- The model is comprised of five key components: capacity building, community N man resources. The economic burden for mental health, livelihoods, research, and management. those who sought treatment was heavy N Involving affected individuals, their families, and communities in a program, as [19], estimated at 25,000 Nepalese rupees well as tapping into local resources, is essential to the success and sustainability (US|S312) for a family per year [20]. of a program. Figure 2 describes the programme N Strategic engagement with government and other stakeholders is critical to matrix of the Nepal MHD model. The demonstrating a project’s capacity to influence mental health practice and scale matrix demonstrates the role of diverse up. sectors in implementing the model, in- cluding the close links with the districts’ government-run health facilities and exist- population of 28.2 million people [13]. no mental health legislation [16]. Nepal ing community structures—a key strategy The country is divided into 75 districts and currently has only one public sector to integrate, and sustain, mental health almost 90% of the population lives in rural psychiatric hospital offering inpatient ser- and development. areas [14]. Nepal’s gross national income vices and 32 psychiatrists. United Mission The initial identification of affected indi- per capita at purchasing power parity Nepal’s Community Mental Health pro- viduals was done by appropriately trained (PPP) in 2010 was US|S1210, ranking 148 gramme between 1990 and 2004, despite key local stakeholders who mobilized these out of 167 [15]. The life expectancy at challenges of sustainability, was an excel- individuals to seek care from the mental birth is 68 years and the literacy rate is lent effort in advocating for integrating health program (Figure 3 has details; [21]). 59% [12]. Long-standing political conflict mental health into primary care in Nepal Service provision followed a collaborative has created additional hardships. Less [17,18]. care model [22]. than 1% of health expenditure is spent The Nepal MHD programme, funded Treatment services started in August 2010 on mental health (0.14%), and there is through the Department for International when the first Mental Health Camps (MHC) were held at the district hospitals in Baglung and Myagdi. Dr. Lumeshor, chief psychiatrist at the Western regional hospital (WRH), Pokhara, attends the camps with his team. The appointment of a senior health assistant as ‘‘mental health focal person’’ in November 2010 in both district hospitals greatly helped to manage the ‘‘flow’’ of mental health activities. How- ever, it soon became clear that the district hospitals could not remain the only point of service provision. The number of patients increased but the frequency of the camps could not be increased, as the psychiatric team was unable to come more often. Besides, for many patients, accessing the hospitals meant four hours to walk each way. Thus, follow-up clinics were started at the Health Posts with the District Health Offices permitting the newly trained health personnel to run them. They, however, needed further coaching and supervision. LEADS provided them with SIM cards for their mobile phones, which they use on clinic days to maintain contact with the chief psychiatrist at WRH. Starting in October 2010, individuals/ families were prioritized for livelihoods sup- port (diagnoses, process, and criteria for Figure 1. The BasicNeeds Mental Health and Development Model. The vision for the model is that the basic needs of all people with mental illness or epilepsy throughout the world prioritizing, see next section) through skills are satisfied and their basic rights are recognized and respected. The purpose is to enable people training and/or cash grants for setting up a with mental illness or epilepsy to live and work successfully in their communities. business or in kind. Simultaneously affected doi:10.1371/journal.pmed.1001261.g001 persons were linked into existing self-help

PLoS Medicine | www.plosmedicine.org 2 July 2012 | Volume 9 | Issue 7 | e1001261 PLoS Medicine | www.plosmedicine.org 3 July 2012 | Volume 9 | Issue 7 | e1001261 Figure 2. The Nepal Mental Health and Development programme matrix. Detailed description of key activities, locations, and resources pertaining to the Nepal Mental Health and Development Programme. Mental Health Camp is a concept popular in India, and refers to a collaborative activity in which a team of health professionals carry out out-patient clinics in community settings at regular intervals. VDC (Village Development Committee) is an elected government body at the lowest level of governance (small group of villages) in Nepal. Primary Health Care in Nepal is provided through a decentralized system. Health Posts (HP) cover an area of 3 to 4 Sub Health Posts (SHP). A Health Assistant (HA) is the In-Charge of a HP. SHP are established in all VDC areas. Auxiliary Health Worker (AHW) heads a SHP. Other staff in a SHP are Auxiliary Nurse Midwife, Maternal & Child Health Worker, and Village Health Worker. Female Community Health Volunteers (FCHVs) are volunteers attached to the SHP/HP and are involved in health education in their communities. They receive an annual incentive from the government. Mothers’ Groups are community-level women’s groups that are encouraged by the government through the VDCs and specifically linked to the primary health care facilities. Mothers’ group meetings are facilitated by the FCHVs. Community-Based Workers (CBWs) are community-based staff recruited by LEADS for the project. doi:10.1371/journal.pmed.1001261.g002 groups (SHGs), opening up opportunities to need, the capacity of the health facilities medicines. At present, MHC held at the integrate into mainstream groups and en- requires further strengthening to provide district hospitals every alternate month are suing opportunities. LEADS’ community- mental health services to a larger number the nearest point where/when the psychi- based workers (CBWs), coordinators, and of patients. atrist is available. LEADS is currently female community health volunteers Between October 2010 and March talking to a local private hospital for (FCHVs) made home visits to provide con- 2011, 55 affected individuals, showing additional psychiatric support. tinuing support to the families and to also significant clinical improvement, were as- The increased or regained capacity of identify more affected individuals. sessed by LEADS for eligibility for liveli- affected persons to work and earn has hoods interventions. A checklist was used been a motivator. However, opportunities Impact, Barriers, and followed by discussions with the individuals are few and earnings are low by any Opportunities themselves and their families. The indica- standards. The lack of development in the tors were: work before illness, interest to region limits the scope of available liveli- Figure 3 provides an overview of the work, ability to work, traditional skills, hoods options. The hilly terrain and sparse characteristics of and benefits for persons family involvement, and market scope. population makes it difficult to bring affected by mental illness accessing the Thirty-one individuals, with varying diag- together a reasonable number of persons MHD program in the short span of the 8 noses (psychotic disorders-11, epilepsy-11, from different villages to form SHGs that months since its inception. common mental disorders-9) were priori- can be sustained over time for self-ad- The most common diagnoses were com- tized for support. In October 2011, LEADS vocacy. Integrating affected persons into mon mental disorders, followed by psycho- carried out an evaluation of the outcomes the innumerable existing village-level sis and epilepsy [23]. Qualified psychiatrists of these 31 individuals. Data collected were: SHGs (which can also help address stigma) made diagnosis using WHO ICD-10 crite- details of business plans, investment made, posed problems, as existing members ria, and thereafter recorded follow-up expenses incurred, income and savings resisted the idea of mentally ill people assessments in individual clinical informa- details as well as their views about progress, joining. Incentivizing the SHGs with re- tion sheets. Of the 311 patients registered problems, family support, financial situa- volving micro-credit funds and skills train- with the program until March 2011, 269 tion, and future plans. Initial findings ing has helped to integrate affected per- have been reported to show improvement. showed that all 31 were earning in a range sons to some extent. Over time we saw an increasing number of of occupations including running a tea/ In Nepal, primary health care is offered identifications from home visits and some grocery shop, chicken and goat rearing, through a decentralized system [24]. The self-referrals. tailoring, and embroidery. The six who MHD programme already works through Baseline data collected at MHC showed earned prior to the program observed an this. Continued engagement with health 142 had accessed pharmacological treat- increase in income ranging between 17% facilities, support to affected persons and ment earlier, the vast majority from and 108%. Two individuals with epilepsy families for livelihoods, and repeated awa- private providers in Kathmandu (4 days were doing skilled work (tailoring and reness activities over time will help inte- travel) or Pokhara (2 days). Apart from the making copper pots) and reported monthly grate the model into the routine activities travel costs, these families also paid for the earnings well above the stipulated mini- of the existing providers and communities, consultation and medicines. All of them mum wage. Two persons diagnosed with but funds for sustaining these activities will now attend MHC at the district hospital depression, whose occupations were run- be required. Continued political instability (4 hours travel maximum) and follow-up ning a provision shop or tailoring, earned in Nepal has delayed LEADS’ plans clinics in their local health posts, do not close to the minimum wage. The rest have for engaging with the government more pay for services or medicines, are regis- incomes below the minimum wage. Ten substantially. tered as Out Patient Department (OPD) have deposited savings with LEADS to be patients, and are therefore part of the transferred into the account of a livelihoods Looking to the Future district health management information co-operative that has been initiated. system (HMIS). The program has experienced a num- In the two districts the plan is to expand Of the 311 persons who have so far ber of barriers in its implementation. access and sustain the program by building accessed the program, 32/214 (15%) of Villages in both districts are remote, almost capacity in local resources by training those who were not in an income-gener- entirely inaccessible by road, and distances more local doctors in mental health (both ating occupation began earning an in- are still measured in number of days to private and government); holding MHC in come, and 22/48 (46%) of persons who walk. Despite the inhospitable terrain and remote locations so persons living there were not engaged in any form of produc- associated difficulties, demand for services have easier access to specialist attention; tive work (e.g., household chores) began is growing and a key challenge is to keep training and supporting all health posts to such work. While this is low proportion pace with supply—i.e., availability of psy- include mental health records in HMIS; relative to the estimated epidemiological chiatrists, trained health personnel, and widening the scope of training for health

PLoS Medicine | www.plosmedicine.org 4 July 2012 | Volume 9 | Issue 7 | e1001261 PLoS Medicine | www.plosmedicine.org 5 July 2012 | Volume 9 | Issue 7 | e1001261 Figure 3. Characteristics and benefits of the users of the Nepal Mental Health and Development Programme. Upper left: Breakdown of diagnoses for all users of the program. Total number of users is 311, with 134 males and 177 females. Upper right: breakdown by gender of new individuals accessing treatment during the periods (I) July–September 2010, (II) October–December 2010, and (III) January–March 2011. Center: breakdown of diagnoses patterns for new individuals accessing treatment during each of the periods (I) July–September 2010, (II) October–December 2010, and (III) January–March 2011. Bottom: source of identification of new individuals accessing treatment during each of the periods (I) July– September 2010, (II) October–December 2010, and (III) January–March 2011. *Common mental disorders refers to anxiety, depression, phobia, and psychosomatic disorders. doi:10.1371/journal.pmed.1001261.g003 workers and FCHVs to support livelihoods oriented mental health interventions in provide the ‘‘great push’’ required to set interventions; establishing a livelihoods LMICs as well as developed countries. up mental health and development servic- cooperative; training affected persons to Strategic engagement and effective es in places where they are not on the evaluate services; and forming district-level working relationships with and involve- agenda of government or civil society [25]. advocacy groups of affected persons. ment of government and other local/ LEADS will step up its engagement with national stakeholders is critically impor- Acknowledgments the Primary Health Care Revitalization tant if a demonstration project has to in- Division for policy changes, especially on fluence mental health practice and policy We wish to acknowledge the valuable contribu- psychotropic medicines allowed at the pri- for scale up. Involvement of affected tions made by Dr. Lumeshor, Chief Psychiatrist, mary care level and budgetary allocations persons and families is fundamental for Western regional Hospital, Pokhara, Nepal, and the following individuals from LEADS, Nepal: for mental health. Ultimately, lessons from maintaining relevance and effectiveness of Sarita KC, Bir Bahadu Thapa, Mona Bhandari, the experiences in Baglung and Myagdi, interventions even if they are evidence Padam Gautam, Mim Kumari Poudel, Meena and evidence from a cohort intervention based. Advocacy by affected persons is Pun, Ratika Mijar, Shoba Kaucha, Than Maya study (underway), will be used for design- powerful and must be supported to be- Srish, Laxmi Thapa, Geeta Mizar, Chitra ing a scaled-up programme in six more come effective. Community involvement is Thapa, Padma Shrestha, Santosh Limbu. districts in the Western Region. important, as it supports affected persons We are grateful to Sabina Jancy and Lata BasicNeeds has implemented the MHD and families in the process of recovery and Jagannath from the BasicNeeds Policy and model in nine countries. Many of the older can effectively support delivery of services. Practice Office, Bangalore, India, for their programmes have encountered and nego- Involving affected persons, families, and administrative support. Finally, we give our special thanks to the tiated the kind of difficulties we are cur- communities requires detailed planning individuals with mental illness and epilepsy who rently observing in Nepal, and lessons and has to be intrinsic to the intervention have participated in the Mental Health and from those experiences may have rele- programme. Tapping into local or in- Development programme in Nepal. vance in Nepal. In Uganda, for example, country resources, skills, and capabilities advocacy groups now engage directly with will help sustain service delivery. Design- Author Contributions district officials to lobby for improved ing simple yet rigorous records and data treatment services. In Ghana, groups have collection systems for complex communi- Analyzed the data: SR US SM VP. Wrote the come together as a registered national ty-based mental health programmes is first draft of the manuscript: SR. Contributed to the writing of the manuscript: SR CU PS US association, the Mental Health Society of feasible and crucial for monitoring quality SM SKW VP. ICMJE criteria for authorship Ghana (MEHSOG), for advocacy. In Lao and can substantially aid evaluations; such read and met: SR CU PS US SM SKW VP. PDR, mental health services are available evaluations must be intrinsic to the in- Agree with manuscript results and conclusions: through primary care in nine districts of tervention programme. SR CU PS US SM SKW VP. Created the Vientiane capital region. There are a Above all, the MHD model is not in Model for Mental Health and Development: number of lessons from BasicNeeds’ total parallel or an alternative to government CU. experience in 10 years that can be relevant and other local efforts for effective mental more widely in scaling up community- health interventions. The model works to

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