The Role of Non-Governmental Organizations

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Section 6 Human resources and capacity building Chapter The role of non-governmental organizations

36 Robert van Voren and Rob Keukens

My interest is in the future because I am going to leper houses of the Middle Ages. As Michel Foucault spend the rest of my life there. wrote in Madness & Civilization, (Charles Kettering 1948) What doubtless remained longer than leprosy, and would persist when the lazar houses had been empty for years, were the values and images attached to the figure of the leper as well as the meaning of his exclusion, the Introduction social importance of that insistent and fearful figure Non-governmental organizations (NGOs) encom- which was not driven off without first being inscribed pass different types of value-based organizations within a sacred circle ... Leprosy disappeared, the leper depending on donations and voluntary service. They vanished, or almost, from memory; these structures include, among others, local and international char- remained. Often, in the same places, the formulas of ities, research institutes, and lobby groups. The exclusion would be repeated, strangely similar two or United Nations defines the NGO as “non-profit, vol- three centuries later. (Foucault 1965, pp. 6–7) untary citizens’ group which is organized on a local, national or international level. Task-oriented and Psychiatry very much repeated that model, ridding driven by people with a common interest, NGOs society of all the unproductive elements and isolating perform a variety of services and humanitarian them from the rest of society. In the eighteenth cen- functions, bring citizens’ concerns to governments, tury the French statesman Guillaume-Chrétien de monitor policies and encourage political participa- Lamoignon de Malesherbes wrote, “it seems that the tion at the community level” (United Nations, honor of family requires the disappearance from soci- undated). There are more than 40 000 international ety of the individual who by vile and abject habits NGOs active, 90% of which were founded during the shames his relatives” (Foucault 1965, p. 67). Equally, past 30 years (Edwards 2000). The number of in many countries the stigma of mental illness or national and local NGOs is incomparably higher, mental disability became such that often patients were but no statistics exist. Statistics about the number kept indoors all the time, out of sight, and having a of NGOs in mental health are also not available, yet person with mental illness or intellectual disability in it is known that there are not many international the family was seen as a shame that should be kept NGOs active in the field of mental health (World hidden at all cost. Health Organization 2010). In France at the turn of the nineteenth century it Throughout Europe, as well as in most of the was Philippe Pinel who brought about a change in the “developed” world, the mental health system that pre- perception of mental illness when he concluded in his vailed was a highly institutional, biologically oriented Traité de la Manie that insanity was curable. The psychiatry, in which persons with chronic mental ill- fundamental element in this change was Pinel’s belief ness and persons with intellectual disability, as well as that an acute illness manifests a spontaneous dyna- social outcasts, were locked away in institutions usu- mism inclining it towards a cure, and that it tends ally placed outside urban areas – a repetition of the to pass through “successive periods of graduated

Essentials of Global Mental Health, ed. Samuel O. Okpaku. Published by Cambridge University Press. © Cambridge University Press 2014.

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development, stationary state, decline and convales- fairly central in the enterprise of advancing justice ... cence” (Gauchet & Swain 1999). The consequence of It’s not the economical power of an individual that is an this was, according to Pinel, that a patient had to be adequate indication of development, but to which extent kept in a therapeutic environment, because it was a person can use his capacities in the system. (Sen 2009, p. 258) impossible to predict when the illness would end, and recovery could never be completely ruled out. In spite of Sen’s words, a major problem for NGOs is Action against the flaws of psychiatry amongst the low priority that is globally assigned to mental people experiencing mental health problems is not health. new. In 1620 concerned patients of the Bethlem Hos- Across the world, on average only 2% of national pital sent a Petition of the Poor Distracted People in the health budgets is dedicated to mental health, and House of Bedlam, a complaint against inhumane treat- approximately one-third of countries have no speci- ment, to the House of Lords (Barnes & Bowl 2000). But fied mental health budget at all. In effect, it is a moral at the time of the rise of the feminist, gay, and disability issue that lies hidden behind the statistics of the movements, it was the emergence of the patient move- burden of mental disorders – measured in disability- ment in the 1960s and 1970s that brought about a real adjusted life years (DALYs) – and the high levels of change in mental health service delivery. Suddenly con- prevalence, but this does not seem to motivate sumers of mental health services found a voice, and authorities and civil servants to give the state of although often considered to be (too) radical and (too) mental health services more prominence on their demanding, their activism – focusing on empower- national political agendas. Progress in mental health ment, recovery, better services, implementation of service development has been slow in most of the low- user-led initiatives, and rights protection – led to a wave income countries, and mental health is considered a of “democratization” in the field of mental health and a secondary issue in many countries, as well as by gradual change from often highly custodial and pater- virtually all development agencies. Playing the moral nalistic psychiatry for psychiatric patients to a system card does not seem to convince donors, and it is not of community-based and user-oriented mental health clear whether global structures can emerge from care services where all stakeholders have a say in how social and moral principles regarding distributive they are designed and managed. The service users justice that are able to rival constitutional states. movement is predominantly a Western phenomenon, Factors that influence the marginal position on the and in many countries the situation is still far from priority agenda are (Saraceno et al. 2007, McDaid ideal. The tension between what persons with mental 2008, Ventevogel 2008, Keukens & van Voren 2009): illness want, what their carers want, and what profes- A divided lobby and fragmented advocacy by sionals think is best will always exist, but there is no different stakeholders, including NGOs, resulting doubt that, at least in theory, and more and more often in an incoherent message that is easy for policy also in practice, mental health at the beginning of the makers and politicians to ignore. twenty-first century looks fundamentally different The social perceptions of mental health problems from the revolutionary model that Philippe Pinel are dominated by negative stereotypes, leading to designed 200 years ago. stigma, discrimination, and social exclusion. The invisibility of mental health. The low priority of mental health The lack of scientific data on prevalence and Nobel Prize winner Amartya Sen writes in his book outcomes, and on mental health indicators. The Idea of Justice: Growing criticism of the functioning of NGOs The relevance of disability in the understanding of themselves. deprivation in the world is often underestimated. People with physical or mental disability are not only among the most deprived human beings in the world, they are Putting mental health on the also frequently enough the most neglected ... If the demands of justice have to give priority to the removal international agenda of manifest injustice rather than concentrating on the Until the late 1990s, mental health care was not con- long-distance search for the perfect society, then the sidered to be a priority by international development prevention and alleviation of disability cannot be but aid agencies.

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A crucial factor has been the publication by the The prioritization of mental health by (inter)gov- World Bank of The Global Burden of Disease (Murray ernmental bodies continued, and led to many other & Lopez 1996), which for the first time showed that initiatives and documents. A further boost to the psychoneurological diseases had a very significant NGO community in mental heath was the adoption negative impact on the world economy, and that the and ratification of the Convention on the Rights of economic costs of these diseases would continue Persons with Disabilities (CRPD), which clearly stipu- to grow considerably in the years to come. The report lates the rights of persons with disability, and there- emphasized the significant burden associated with fore also of people with a mental disability or mental mental disorders, with five of the ten leading illness (United Nations 2006). The CRPD and its causes of disability worldwide being neuropsychiatric Optional Protocol were adopted in December 2006 disorders, accounting for a quarter of total disability and opened for signature in March 2007. There were and 10% of total burden in 1990. The burden 82 signatories to the convention, 44 signatories to the was estimated at 11.5% in 1998 and was expected to optional protocol, and one formal ratification of the rise to 15% by the year 2020, with the rise being convention, the highest number of signatories of a particularly sharp in developing countries. These data UN Convention on its opening day ever. The conven- resulted in a major shift, as suddenly the economic tion entered into force on May 3, 2008. In particular, impact of mental illness became visible, and it became NGOs monitoring the implementation of the conven- clear that investing in mental health also had an tion became important actors in the field, as well as economic benefit. The World Bank, convinced by those who foster the development of more humane the report and several other approaches to them, and user-oriented services that are more in line with decided in 1999 to hire a mental heath consultant, the CRPD’s framework (United Nations 2010). Professor Harvey Whiteford. Although his tenure A decade after the 2001 World Health Report, the was relatively short, he managed to bring about a WHO published a new world mental health report, major change in the World Bank’s understanding of adding many more data and again emphasizing the the problem. need to invest in mental health care (World The first decade of the twenty-first century saw a Health Organization 2011). Both in the preparation fundamental shift in attitudes towards mental health. of the report and in the implementation programs of In 2001, the World Health Organization (WHO) WHO such as the mhGAP program, NGOs play devoted its annual World Health Report entirely to a crucial role in monitoring implementation and the issue of mental health. The report gave a detailed implementing policies at grassroots level. Later that overview of mental health services throughout the year, a High-level Meeting of the United Nations world, often with shocking data showing the lack of General Assembly on Prevention and Control of adequate services available. Following WHO’s Non-communicable Diseases (New York, September example, the European Commission continued its 19–20, 2011) recognized that mental and neurological political discussions on mental health issues, which disorders, including Alzheimer’s disease, are an reached a temporary climax during the Finish Presi- important cause of morbidity and contribute to the dency of 2004–05. In 2005 WHO and the EU together global non-communicable disease burden, necessitat- organized a European Ministerial Conference on ing provision of equitable access to effective programs Mental Health in Helsinki which led to the signing and healthcare interventions. of two documents: a Mental Health Declaration for And finally, on January 20, 2012, the Executive Europe and a Mental Health Action Plan for Europe. Board of WHO adopted a resolution, titled “Global The documents emphasized the need to adopt a com- burden of mental disorders and the need for a comprehensive approach to mental health covering the prehensive, coordinated response from health and provision of promotion, prevention, treatment and social sectors at the country level,” which detailed care, and social inclusion. Also, and important in the problems facing persons with mental health prob- the context of this chapter, the meeting was a turn- lems and their environment, and also promoted the around for NGOs, as for the first time they were “involvement of civil society organizations, persons officially invited to participate in the process of pre- with mental disorders, families and caregivers in paring the final documents and, subsequently, in voicing their opinions and contributing to decision- implementing their goals. making processes” and the “participation of people

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with mental disorders in family and community life sometimes of a very poor quality with a limited and civic affairs,” and urged the Director-General of experience and scale, not coordinated, and not in WHO “to collaborate with Member States, and as communication with public services, sometimes even appropriate, with international, regional and national in competition with them. non-governmental organizations, international devel- As a result of this tension, their services often opment partners and technical agency partners in the remain unsustainable or become an obstacle to the development of the mental health action plan” development of a more comprehensive mental health (World Health Organization 2012). care program. The authors have observed the influ- Unfortunately, in spite of the fact that mental ence of NGOs in countries in transition over a period health has reached the state of being acknowledged of two decades, and have often observed situations as a priority issue, and also that NGOs are considered where NGOs provide good and necessary services, but an important partner in developing and implement- are fully dependent on external donors (hence not ing national and international mental health plans, sustainable) and available to only a small number of the outlook for the coming years is not altogether a people (hence not replicable). In other cases, services positive one. The 2008 economic crisis, which with provide a short-term answer to an existing problem, ups and downs dragged on well into 2013, severely without investing in a long-term sustainable solution. affected available budgets for reform, and in many NGOs need to establish long-term (> 15 years) part- cases mental health was the first item on the budget to nerships, have a strong (value-driven) vision on suffer budgetary cuts. In addition, however, the out- change, focus on constant cycles of learning, and look on development aid is gradually shifting in frame reflection, as well as balance changing capaci- Europe, with more and more countries being affected ties and structures to induce paradigm shifts (Essink by an “anti-globalist” political course resulting in 2012). more isolationist and self-centered policies. In add- The following sections provide two examples of ition, the overall tendency is to work through large the role of NGOs in mental health care development (inter)governmental agencies, and much less through and provision. NGOs, as an answer to the need for more account- ability, transparency, and large-scale initiatives. Con- Example 1. Sri Lanka following the tsunami: sequently, mental health seems to have become a priority at the worst possible moment, while NGOs trauma care are in practice often sidetracked by large (inter)gov- Much of the foreign aid given to Sri Lanka in mental- ernmental agencies that tend to work through gov- health-related areas has been concentrated on initia- ernments rather than through grassroots tives connected to the war in the north, in which more organizations. than 70 000 persons were killed over a period of 26 years. The constant displacement of people, the dis- ruption of social networks and services, as well as the The role of NGOs: examples violence, all these factors resulted in enormous levels NGOs, or non-state actors (NSAs), can have both a of suffering and distress within the communities in constructive and a destructive influence on the devel- these areas. The aid was primarily given to a multi- opment of mental health care in specific regions or tude of NGOs that, often under adverse circum- countries, and sometimes their effect on the ground is stances, worked with those affected and tried to a combination of both. It is often NGOs that initiate create a support network. For many organizations new approaches in care and other innovations; or in foreign aid remained the primary or even only source countries where care is virtually absent they provide of income. services that would otherwise not be available (almost Even while the war was in progress, a growing half of the world’s population lives in a country number of foreign donors started to scale down their where, on average, there is one psychiatrist or less to support, and the tsunami disaster of December 2004 serve 200 000 people: World Health Organization was pushed to the background as a result of other 2011). Also, NGOs often have the leading role in natural and manmade disasters elsewhere, with the social services at grassroot level. They are sometimes result that many of the remaining NGOs struggled to of an excellent quality but also, unfortunately, survive and continue their operations. Decreased

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funding, lack of staff, burnout, and pessimism about framework within which trauma care could maintain the future of the armed conflict led to an ever- itself, and the specialized trauma care would give increasing difficult situation. Ironically, the situation extra capacity and specialized services to mental was to some extent even aggravated by the “tsunami” health care services that are needed to deal with trau- of competing health volunteers who rushed to the matizing situations. In more general terms, the exist- island after the tsunami to spread the blessings of ence of regular, sustainable, and nationwide Western counseling techniques and (sometimes obso- community-based mental health care services would lete) post-traumatic stress disorder (PTSD) treat- make a lasting response to trauma much more effect- ments among the victims, by doing so tearing the ive in future (World Health Organization 2011). local social fabric apart (Watters 2010). At the same time, it is important to note that there Although the tsunami resulted in a number of is now a growing understanding that post-trauma post-disaster trauma care initiatives developing into care following a natural or manmade disaster is regular community-based mental health care services, often relatively useless, and in some cases even most of the foreign donors did not follow this devel- counterproductive (Young 1995, Ventevogel & Jong opment and limited their funding strategies to sup- 2006, Summerfield 2008). As Watters notes in his porting post-conflict or post-disaster initiatives, analysis on the impact of psychosocial trauma staying away from regular mental healthcare service help in Sri Lanka following the tsunami, “Western delivery. This was the result of a combination of traumatologists have developed a set of beliefs about factors, with on the one hand a mistaken understand- how best to heal from the psychological effects ing of the nature of mental health care services in of trauma ... Against a growing body of evidence, general (usually seen as purely medical and targeted at traumatologists assume these ideas to be universally only a very small part of the population) and on the true” (Watters 2010, p. 31). People need to fall back other a series of limitations arising from the origin of on their own resilience and coping capacity, and the funds, the criteria for rendering support, and the the initial focus is on getting back to a sense of background of the donor organization itself. Often “normalcy” as quickly as possible. This includes when a link was forged between existing mental ensuring that services and support networks are sup- health structures and services and activities and pro- ported and that the disruptions of people’s lives, jects deployed by NGOs, it was an exception and not as well as the medicalization of their needs (since part of a consistent strategy. perceived mental health problems may be a normal The result is that mental health care development human response to living in a stressful context), are in Sri Lanka, even at this crucial and challenging time minimized as much as possible. when a structural development towards community mental healthcare services can be brought about, is under-funded and not a priority for foreign donors. Example 2. GIP in post-totalitarian societies The long-term governmental policy (2015) is ambi- Global Initiative on Psychiatry (GIP: www.gip-global. tious and aims at the development of accessible org) was founded as the International Association on mental healthcare services delivered by an adequately the Political Use of Psychiatry (IAPUP) in December trained staff, with an emphasis on prevention and 1980; it later became the Geneva Initiative on Psych- rehabilitation and community-based services (Mental iatry, and in 2005 changed its name to Global Initia- Health Directorate 2005). However, at the same time tive on Psychiatry (van Voren 2009, 2010). After the only 1.6% of the total health budget is spent on mental collapse of the Soviet Union in 1991, GIP entered the health, the staff-to-population ratio is inadequate, and field of mental health reform. Started as an inter- a lot of the post-conflict/disaster NGOs are struggling national campaign against the political use of psych- to survive and are functioning often in isolation, iatry, it answered the call from Soviet psychiatrists without larger support mechanisms and under and dissidents alike to help develop humane, ethical, adverse circumstances. and user-oriented mental health care in the formerly A stronger link between structural mental health communist countries. One of the first priorities was care service development and post-conflict trauma to develop an NGO sector, because no independent care would be beneficial to both sides. Community organizations previously existed. In the late 1980s and mental health care services would provide a structural early 1990s the first new independent psychiatric

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associations were set up, the first one being the Inde- translation and publication of modern mental health pendent Psychiatric Association (IPA), set up in literature into Georgian, the opening of a Resource Moscow with close involvement of GIP. In 1992 the Center on Mental Health at Ilia State University in first organizations for relatives were formed, as well as Tbilisi, the organization of a wide range of intensive professional associations such as those of psychiatric trainings, workshops, and conferences, as well as nurses and, later, social workers. Because of the enor- exchange visits and research activities. mous stigma prevailing in post-totalitarian societies, At the national level, the main strategy of the only in the late 1990s the first user groups were set up. NGO community was to influence the government The emergence of an active NGO sector had a and other mental health policy makers to adopt legis- profound impact on mental health care development lation and to abide by the new laws, to develop rele- in this part of the world. Most of the innovations in vant mental health policies and plans, and to help mental health were started by NGOs rather than by create monitoring mechanisms to ensure the protec- governments, and pressure from the NGO commu- tion of human rights. For more information on the nity helped to convince local and national govern- reform process in mental health in Georgia and the ments that the existing services were not meeting role of NGOs see Makhashvili & van Voren (2013). the needs of the population. Very often, people from the NGO field later became key individuals within governmental circles, pushing for reform from Legitimacy of NGOs in mental health within. Even though the governmental bureaucracies NGOs have become increasingly influential in world. often resisted reform and sided with directors of The World Bank estimates that over 15% of total major psychiatric hospitals, who viewed reform as a overseas development aid is channeled through threat to their positions and influence, in the course NGOs (although probably not much of this concerns of 10 years the outlook changed fundamentally and the rather few NGOs working in the field of mental the need to develop community-based services was health). However, there are a number of important generally accepted in most of the countries, the main issues to consider. Their increasing (economic) influ- issue of debate remaining what community psychi- ence with only limited checks and balances in place, atric services actually are and to what extent the old their shift from lobbying activities on behalf of a institutional system should be discarded. specific target group to becoming involved in the For instance, in the Caucasian former Soviet work of intergovernmental institutions, policy imple- Republic of Georgia, one of the essential elements in mentation, and service provision (which in turn often the reform process in mental health during the past results in becoming caught up with political and two decades was the strong voice of the NGO sector. commercial interests) – all these factors raise ques- The activity of civil society organizations, professional tions with regard to the legitimacy of NGOs. societies, user groups, and family member organiza- At the same time, this shift in the positioning tions created the momentum that was essential for a of NGOs has to be seen against the backdrop of a movement towards a rights-based and humane process in which primacy lies more and more with, mental health care. The sector often functioned as e.g., notions concerning human rights or distributive the conduit for international expertise and knowledge justice rather than the priorities of specific nation about best practices in other countries. states. In searching for innovative, locally appropriate, We cannot expect NGOs to fill the vacuum and implementable models, new projects and created by failing nation states, for instance by calling activities were developed by NGOs. Many new attention to the fact that in many countries there is community-based services, such as crisis intervention hardly any psychiatric care for the population and the and home care, were rolled out through the approach only available services are concentrated in large, often of starting with small pilots that were followed by a deteriorated hospitals. Nor can we expect NGOs to be national scale-up financed and implemented by state the ones who have to ask governments why persons structures. with mental health problems are excluded from In challenging the old model of psychiatry and employment or education or decent housing. Yet it introducing contemporary approaches, capacity- is legitimate to point out shortcomings, to give a voice building activities were promoted, such as the to people with mental health problems who belong to

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the most vulnerable groups in society (World Health China, for instance, has a broad and vague definition Organization 2010), and to put social and moral of what constitutes foreign aid but is becoming a themes on the international agenda as a way to con- major source of “development aid,” although yet dif- tribute to a transcending democracy. ficult to quantify. Some of Chinese assistance resem- However, if legitimacy is practicing power on bles foreign aid as defined by the OECD, but it also behalf of citizens to whom you are accountable, shares characteristics of foreign investment. The nation states are in principle bound by democratic major drive behind the non-transparent Chinese pro- procedures. In contrast to nations, NGOs strive to grams, which often take the form of cut-rate loans, is realize specific ambitions and do not have to account to secure and transport natural resources and to for the potentially conflicting interests of all citizens. establish diplomatic alliances. Lum and colleagues The activities of NGOs are often not based on or (2009) noted in a report on China’s growing role in legitimized by democratic procedures, and they bear Africa, Latin America, and Southeast Asia that their responsibility only to their financial donors. offerings are well received, not only because many of The question to what extent the pretentions of the funded works are highly visible and provide short- NGOs are democratically verified is further problem- term effects such as the construction of highways and atized in the case when an NGO fails to practice what railroads, but also because the Chinese support comes it preaches. Does respecting clients’ rights and involv- without the usual bureaucratic procedures and the ing them in decision making mean in fact that they focus on social, political and environmental condi- actually participate in designing project proposals, or tions that Western donors and NGOs impose. does it mean that they are represented in the boards Whereas Western NGOs operate within the frame- and staff of the relevant NGOs? Is giving voice to work of ethical guidelines, with their emphasis on vulnerable persons with mental health problems a human rights, China offers quick solutions, a mix of form of political correctness or is it based on consen- aid and business in secret government-to-government sus among the target group? Is this rhetoric system of agreements (LaFraniere & Grobler 2009). thought with non-offending ideas about “human Moreover, in Western countries the economic values” going to dominate the debate and transcend recession can lead to a significant reduction in foreign the global cultural diversity with its myriad notions aid. Past economic crises have led to trimming gov- on mental health? ernmental foreign aid budgets and a substantial decrease in contributions by foundations and NGOs. Experience from the past showed that drastic cuts NGOs in the modern age resulted in an increase of poverty and reduced the Rapid changes in the global economic landscape will supply and quality of healthcare services (USAID have profound effects on foreign aid and the role of 2009). At the same time, since mental health and NGOs. While Europe and the United States are poverty are closely linked, with those on low incomes plunged into an economic crisis, Brazil, the Russian more likely to suffer from poor mental health and Federation, India, and China (BRIC) have the poten- poverty contributing to poor mental health (Jenkins tial to form a powerful economic bloc based on their et al. 2008), the demand on mental health services will roles as global suppliers of manufactured goods, ser- increase. vices, and raw materials. By 2030 the four BRICs may The shifts in global economy are reflected in account for 41% of the world’s market capitalization changes in priorities and ambitions in foreign aid. (Moe et al. 2010). In the wake of economic growth, New players in the field are motivated by their countries that once were on the receiving end of national interests, while the traditional donors re- foreign aid now mount the international aid platform evaluate their strategies and policies in light of their as donors. However, while over the past decade the economic recession. wealthy traditional donor countries cleaned up their assistance programs under the umbrella of the Organ- isation for Economic Co-operation and Development The road ahead (OECD), which set rules and norms with regard to Edwards and Zadek (2003) identified two, often con- foreign aid, the BRIC countries are not member states tradictory, imperatives that need to be reconciled of the OECD and thus not bound by these rules. when non-state involvement in global governance

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complements governmental decision making. First of ultimately does. We know, for instance, remarkably all, the diversity of non-state actors and the inequal- little about the long-term effects of humanitarian ities among them make rules and protocols essential. activities in the field of mental health. NGOs should Secondly, these rules and standards should be non- strive to improve the evidence base of mental health bureaucratic to prevent undermining the beneficial interventions, and to develop best practices and characteristics of these organizations. Edwards and effective culturally adapted interventions – in terms Zadek provide a list of general recommendations to of outcomes and cost-effectiveness – as well as strike the balance between the two directives. These consensus-based indicators to substantiate the ration- “rules of the road for non-state actors” comprise ale for including mental health on the national suggestions to enhance the legitimacy of the NGOs agenda. Such developments are necessary not only (for instance by ensuring transparency with regard to to compete more effectively with other and more their legal status and funding), and also how to general health needs, but also to legitimize inter- strengthen their role in global governance (for national efforts and involvement. When competing instance by providing – financial – support to local for available funds with general health needs and actors with fewer resources). priorities, mental health is in arrears on providing One of the key barriers that has prevented evidence of its effectiveness. improvement in mental health is fragmentation The problem in mental health is that, no matter among mental health advocacy groups (Thornicroft how much our knowledge of genetic and physio- & Tansella 2008). Too many global mental health logical processes has progressed over the years, a initiatives targeting specific needs run in parallel and nosology of psychiatry based entirely on neuroscience potentially add pressure to already weak health not only seems unrealistic for decades to come but is systems. From a broader perspective, setting aside perhaps “impossible to achieve at all” (Greenberg differences and forming alliances and umbrella 2010). Moreover, it is clear that mental health prob- groups with a clear-cut message, as well as main- lems cannot be understood without taking into streaming mental health into more general advocacy account the sociocultural context in which they occur; programs and overarching themes (e.g., poverty social conditions and experiences during the course of reduction within the framework of the Millennium life play an important role in the etiology of mental Development Goals, human rights and service user health problems, limiting the applicability of inter- empowerment), could strengthen the lobby for ventions. A panacea for mood disorders similar to mental health. Key issues that can function as a immunization for polio is unrealistic and utopian. common denominator are the implementation of Hence, NGOs should rather prioritize and advocate the CRPD, advocating for (new or improved) mental for patients’ rights and improving the quality of care, health laws and national policies, anti-stigma and and, in short, support the basic demands of the client anti-discrimination arrangements, and the implemen- movement in mental health, rather than rub against tation of human rights. the “vigorous effort to remedicalize psychiatry” To increase the efficacy of the advocacy efforts of (Sabshin 1977). NGOs, the development of lobby and training pro- NGOs must also build their legitimacy by prac- grams in the sphere of public relations, among others ticing what they preach. Besides being transparent regarding the use of social media and networks, is key and accountable to donors and the general public, to address politicians and policy makers who have a global NGOs must ensure that local partners are limited understanding of the issues surrounding included in the debate, and must empower the “target mental health and also have limited time to make group” to participate in reform and act and speak for informed decisions. Reduction in negative media por- themselves. NGOs in mental health should therefore trayal may lead to mobilizing (financial) resources involve people who have experienced mental health and a reduction of stigma. problems in their organization. These people have NGOs are much criticized (e.g., De Waal 1997, expertise and can build effective partnerships between Polman 2010). Serious questions are raised with client and family organizations, mental health regard to the issue to what extent their support affects providers, and other stakeholders to streamline advo- economic development and how much good aid cacy and build a “critical mass.”

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Section 6: Human resources and capacity building

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Chapter 36: The role of non-governmental organizations

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