Capacity building, Underhill explained, involves contacting persons in a community, particularly those who are mentally ill and those with epilepsy, as well as their caregivers, families, friends, and representatives of community groups. They are invited to community meetings conducted in a room at a district hospital, in a schoolyard, or even outside under a grove of trees. Participants usually divide into 3 groups: persons with mental illness or epilepsy, the caregivers, and persons working with local health facilities and community organizations.
"We bring people together and ask them simple questions: What is your world? (In other words, what is happening to you and around you?) What are your needs? How do you want to go forward?" Underhill said.
In that process, those with mental illness or epilepsy are given, often for the first time, a voice in how they want to be treated and how they want their treatment to proceed. They demonstrate to themselves, to their caregivers, and to community representatives that they are capable of lucidly discussing their lives and concerns.
"They know the results they are looking for. . . . They want treatment, which they hope will reduce the symptoms they are experiencing and give them a more normal life, and they want to make contributions to the family income. In the case of heads of family, they want to go out and earn an income like they used to," Underhill said. "When you are sitting in the room and quietly watching and the mentally ill people stand in a group [often comprising 60 or more people] and start to go through the issues they have put down on their flipchart, a silence spreads across the room. That moment is extraordinary, because it is the first major chip away at stigma that exists between [caregivers] and mentally ill people." To clarify, he explained that up until that moment, caregivers often considered individuals with mental illness solely as a burden, an attitude frequently shared by others in the community.
At the meeting, all 3 groups discuss with BasicNeeds how to arrange for medical and psychiatric treatment, how to form ongoing groups, and what needs to be done. Central to this part of the model is the creation of communitylevel voluntary committees that include persons whose mental illnesses is stabilized, caregivers, and community volunteers. Partnerships are created with women's groups, rehabilitation organizations, and other associations.Community mental health
The second component of the model is community mental health. BasicNeeds does not give direct treatment. Rather, it usually works with the country's ministry of health to create mechanisms by which persons with mental illness or epilepsy can easily access services. Typically, the government provides a psychiatrist, psychiatric nurse, or other mental health professional. A group in the community hosts the specialists.
At a designated location in a community, the psychiatrist begins seeing and assessing patients, many of whom have suffered from mental illness for up to 25 years with no diagnosis and no understanding of why they feel as they do.
Training workshops for partner staff, health service providers, government officials, medical practitioners, community leaders, and elected leaders of local governments are also provided.
Underhill explained that the training process can be likened to a pyramid-selling technique. "Instead of selling makeup, we sell the idea of how to treat mentally ill people." A psychiatrist may train local doctors on how to diagnose and treat mental illness. A small number of psychiatric nurses are taught how to train others to care for those with epilepsy or mental illness. The psychiatric nurses, in turn, train the general health staff in communities, such as nurses or assistant nurses.
In Dar es Salaam, a port and capital city of Tanzania, Underhill said the pyramid-training process was used to train 150 general health staff members in 3 areas of the city. Before the BasicNeeds model was implemented, 3 to 15 mentally ill persons would turn up monthly at local dispensaries, with many of them being misdiagnosed or referred for treatment to facilities many miles away. Now, at the same local dispensary, 30 to 45 persons are being appropriately treated each month.
The medications provided, Underhill noted, are usually generic versions of psychotropics that are less expensive but may be prone to causing more side effects. In some countries, the medications are free but limited; in others, the government subsidizes a portion of the cost, while the remainder must be paid by the patients and their families.
Because they often need to purchase their own medications and because they need to contribute to the financial support of their families (the average family income in the groups with which BasicNeeds works tends to be about US
50 per year), individuals with mental illness or epilepsy receive guidance from BasicNeeds and community organizations in earning a living.Sustainable livelihoods
The third component of the model is sustainable livelihoods.
"Livelihood is where people are earning money or where they are making a contribution by doing something in their family," said Underhill. "About 64% of our current 28,400 patients/clients are earning or contributing; 22% are earning an income and 42% are engaged in productive work or have gone back to school. An example of productive work is when they help with the family farm plot."
That is something patients can be proud of, he added, and it would not have happened without the assistance of the voluntary community organizations and other partners.
For some individuals with mental illness or epilepsy, small-scale horticultural projects enable them to grow and harvest vegetables for their families. Others, with the help of community groups, are involved in micro- enterprises, such as brick making, goat rearing, and candle and incense stick making.Research
The fourth component of the model, research, focuses on encouraging persons with mental illness or epilepsy to articulate their perceptions about their situation and needs and create their life stories, which may later be published with their permission in Mental Health and Development, the e-journal produced by BasicNeeds.
In addition, files are created on each person, documenting his or her diagnosis, medications taken, and progress, particularly with regard to income generation or contributions to the family. Those data are aggregated, enabling BasicNeeds' policy and research team, based in India and Sri Lanka but working worldwide, to produce consolidated review reports from country programs every 6 months.Management and administration
The fifth component of the model, management and administration, involves work with the government departments in each country and with community-based partners (generally not-for-profit organizations).
It is important to have the government on board, so that the organization knows it is welcome in the country, said Underhill. Government departments are also usually the main players when it comes to the delivery of mental health care and providing resources, so the organization needs to partner with them, especially since it is the government agencies that often provide the psychiatric interventions.
BasicNeeds also provides training to its community-based partners in project management, including "logframes" (logical framework tools for project design), budgeting and finance, monitoring and evaluation, and reporting.Role for US Psychiatrists
Asked how US psychiatrists might assist BasicNeeds, Underhill said the organization is contemplating starting a worldwide fund so that more psychiatrists and psychiatric nurses from developing countries in Africa and Asia can receive training. US psychiatrists could help with that project.
"Second, it would be possible, perhaps on a volunteer basis, for competent and very experienced psychiatric staff to offer their services to help us run some of the shorter training courses, especially those related to diagnosis," he said.
US psychiatrists and other mental health professionals attending the 19th annual U.S. Psychiatric & Mental Health Congress, November 16 to 19, 2006, in New Orleans, will have an opportunity to learn more about the organization; Underhill is scheduled to be 1 of the presenters, and the organization plans to have a booth in the exhibit hall.
In assessing his life's work, Underhill emphasized the satisfaction he felt in seeing his organization reach and help those in need and serve as a model for others to emulate.
The organization's success can be demonstrated by the impact it made on one life. Juma Ali Livinda, a young man with mental illness, was brought in with chains and shackles on his hands and legs to a community meeting in Tanzania arranged by BasicNeeds. Nine months later, because of total care he received at a nearby health clinic, including the provision of psychotherapeutic drugs, he was no longer chained and shackled and was working productively on a cashew farm.3