Chris Underhill has created a movement in the field of mental health that expands existing talent in local communities and puts the mentally ill and their families in charge of resolving challenges. Chris has spread his model across the developed and developing world, and in this process normalized the integration of the mentally ill into society as active and engaged citizens.
The New Idea
Chris has pioneered a model for mental healthcare in the developing world that focuses on treatment and livelihood development through peer groups in local communities. He is changing the landscape of mental healthcare provision in countries where mental health issues are ignored or stigmatized and where there are few resources to provide mental health services.
After launching and building an organization to address the needs and treatment of the disabled in the developing world, Chris honed his approach to focus on the even more marginalized population of those with mental illness. Through BasicNeeds, he built an approach to treating and supporting the mentally ill that is systems-changing because it is based on leveraging existing resources and skills in the community, supporting the mentally ill and their families in advocating for themselves and their needs, and developing evidence to change government policy to better meet the needs of the mentally ill.
Through his work with BasicNeeds, Chris has created a new movement out of participatory rights-based approaches to mental health. Rather than provide services directly, BasicNeeds mobilizes psychiatric clinicians from the public sector and health volunteers from the community to coordinate weekly or monthly mental health clinics in outpatient health centers and follow-up care in people’s homes and neighborhoods. BasicNeeds enables the mentally ill to participate fully in society and earn a living so that they are no longer dependent on those around them.
Mental illness has an enormous impact on the lives of the individuals who suffer and on their families and communities, yet the global response is totally inadequate. Most countries simply do not take mental illness seriously. 40 percent of countries have no mental health policies and 25 percent have no mental health legislation. One-third of the world’s people live in nations that invest less than 1 percent of their total health budget in mental health and this is especially the case in low-income countries where there is a tremendous lack of trained personnel, medication, and facilities.
In developing countries 75 percent to 85 percent of people with severe mental health conditions do not have access to needed mental health treatment. This compares with 35 to 50 percent of people in high-income countries. Mental health services in developing countries—where they exist at all—tend to focus on the diagnosis and provision of treatment for an individual. There are few examples of programs which take the context of family and community into account. Yet the primary need of the mentally ill is access to care in their communities. In most countries the psychiatric services are only located in the capital city and are inadequate to cope with the demand. Community care facilities have yet to be developed in about half of the countries. Even where there are community care facilities, they often are not available outside of the main cities. Mental healthcare is simply not available through local health services. Currently, mental healthcare relies on placing the most mentally ill individuals into a limited number of institutions. This model of treatment is extremely costly and does not look at how the individual will be reincorporated back into the community.
Advocacy for mental health has traditionally been weak because people with mental health problems and their families are too often invisible, voiceless or at the margins of society. Those with mental illness experience widespread stigma and discrimination, are subject to violence and abuse, they find it harder to get work, and to participate and be productive members of the family and community, they are more prone to other forms of illness and disease, find it harder to access health, education and social care, and in many countries they, or their families, must meet the costs of their own healthcare.
From his experience of living and working in developing countries and working with the disabled, Chris understood that resources for care needed to be geographically decentralised so that care could be provided by and made accessible in the community. With such limited amounts of money being invested into the provision of mental health services Chris realized that the only way to make treatment available for the large numbers of people that needed it would be to leverage what existing resources were available by up skilling members of the local community and enlisting the support of the families of the mentally ill.
BasicNeeds works with other citizen organizations (COs) and local healthcare providers to facilitate regular mental health camps where mentally ill people can access treatment and other services. At a mental health camp, mentally ill people and their caregivers from the surrounding area all come together to be seen by a psychiatrist, gain access to medication and take part in group therapy sessions, occupational therapy sessions, consultation meetings, or advocacy groups. This system allows the mentally ill to easily access their treatment, often only minutes from their home. They no longer have to pay for expensive transport and they do not have to spend a whole day traveling just to visit the psychiatrist.
Local volunteers are trained to support other community workers and medical professionals in their jobs. This releases trained professionals from many duties and gives them time to tackle serious and more complex cases. For example in Sri Lanka, community volunteers are a central part of the program and play a large role in follow-up care. Many of the community volunteers in Sri Lanka are stabilized mentally ill people so they are keen to be deeply involved in the program and have a special insight into the work. Where necessary, BasicNeeds also trains primary healthcare staff so that the mentally ill can be identified by all doctors and nurses and receive the correct treatment quickly and efficiently.
For a large number of those with mental illness or epilepsy, access to the right medication and follow-up care will make a dramatic difference in reducing their symptoms, enabling them to return to their previous employment or start a new job. Chris has always stressed the importance of the mentally ill to be able to earn an income, as this changes their position in the community from being considered a burden to becoming a productive member of the community. He has always believed that it is not just enough to provide access to treatment but that to make a full recovery the mentally ill must become full economic citizens. BasicNeeds therefore provides microcredit schemes for people to start small businesses, or horticulture and craft projects where people can learn new skills. The organization also works with communities to overcome stigma and abuse. At the heart of their work is consultation with—and participation of—the mentally ill and their own drive and the drive of their families to solve their own problems.
Over the past thirteen years Chris has steadily grown BasicNeeds to become the largest global operator in mental health. To date the organization has worked with over 85,000 people. 60 percent of the organization’s beneficiaries are mentally ill and 40 percent suffer from epilepsy. BasicNeeds currently runs programs in a total of twelve different countries in Africa, Asia, and Europe: Ghana, Kenya, Tanzania, Uganda, India, Laos, Nepal, Pakistan, Sri Lanka, Vietnam, China, and the U.K. In line with Chris’ vision for local sustainability, the longest standing programs, in India, Uganda and Ghana have now moved to establishing independent local entities, with their own local boards. Chris’ latest innovation is to scale up the application of the Mental Health and Development Model through social franchising, an approach proved to work in community health in developing countries, e.g. by Marie Stopes, but never before used in mental health. The entrepreneurial vision behind this strategy will enable scale up to reach 500,000 individuals with mental illness by 2016.
Chris has worked tirelessly to raise the issue of mental health on public health agendas by carrying out innovative research to evidence the need for greater intervention. One of the biggest challenges when Chris started working in this field was the lack of reliable data, which could prove the scale of the need for mental health services in developing countries. Without this data, governments would not commit more money from their already overstretched budgets to mental health services. Chris was therefore adamant that from the very beginning BasicNeeds would capture data on every single person with whom they worked. Today, having worked with over 85,000 people, the dataset that Chris has generated is one of the most powerful tools he has to affect policy change.
Another equally powerful tool is the grassroots advocacy movement that Chris has helped to coordinate. One of the key elements of Chris’ approach is to bring the mentally ill together to form user groups. These groups are then able to self-advocate for the changes they want to bring about. In Ghana BasicNeeds has helped form 239 user-led groups, which represent the voice of the mentally ill at district and national levels. These groups have been so successful in advocating for change that Ghana now has a registered national user association with a secretariat that represents their needs and rights.
Through this combination of credible data and grassroots pressure, Chris has succeeded in influencing policy both on a national and international level. For example, Chris worked with the World Health Organization in developing the groundbreaking mhGAP Intervention Guide, and BasicNeeds country offices have played a significant role in national mental health policy reforms in Uganda, Kenya, Tanzania, Sri Lanka, and Lao PDR. While Chris has played an instrumental role in facilitating these reforms, the actual draft mental health policies are called for and reviewed by the people with mental illness themselves. For example, in Uganda BasicNeeds brought together 300 users and carers from self-help groups to review the draft mental health bill and policy, which culminated in the National Strategy on Mental, Neurological, and Substance Abuse Disorders Policy.
Globally, Chris is now widely recognized by the World Health Organization, and leading academics in the field of global mental health, as a pioneering leader in community-based approaches to tackling mental illness. Through BasicNeeds, Chris has proven that cost-effective mental-healthcare can be delivered in the community setting.
Chris is a serial social entrepreneur who has dedicated the past thirty-four years of his professional life to improving the lives of marginalized people both in the U.K. and overseas. Over the course of his career he has founded and directed three different COs: Thrive (1978) a U.K.-based CO working with disabled people and medical professionals in horticulture, gardening, and agriculture; Action on Disability and Development (1985) focused on promoting self-advocacy among disabled people in the developing world; and BasicNeeds (1999) his current venture.
Born into a family of artists (his mother was a writer and his father a painter), Chris had an unconventional upbringing and spent his early years living on a boat with his parents, sailing around the coast of France, Spain, and Italy. He later went to study at Dartington Hall School, a progressive school that provided a minimum of formal classroom activities and instead focused on providing other less academic activities such as horticulture and pottery. Chris met his future wife there when he was 16 and got married at 21. He describes this as a stabilising factor in his life, which freed him up to pursue his entrepreneurial interests.
With his wife he moved to Zambia to teach agriculture and later worked for Voluntary Service Overseas as an agricultural officer. During his time in Africa Chris and his wife travelled to Malawi on holiday. While they were there his wife suspected that she might be pregnant with their first child. To confirm whether she was expecting they went to the hospital in Lilongwe to carry out a pregnancy test. The test came back positive and Chris and his wife were overjoyed. However as they walked out of the hospital they were confronted by a cage with three men and women inside, who were being poked at with sticks. Chris realized that that these people had schizophrenia and they were being abused because of their condition. This was a formative moment for Chris and he decided then and there that one day he would do something to help people with mental illnesses.
After writing his dissertation on horticulture as a therapy Chris set up Thrive, in his late twenties, to focus on the social benefit of gardening for the disabled and the elderly. This was a huge learning curve for Chris and he spent ten years directing the organisation before leaving to set up Action on Disability and Development.
Action on Disability and Development was inspired by the work of the disability movement in Zimbabwe, where organized self-advocacy by disabled people’s organizations was having an impact on attitudes and policy. After spending time there Chris realized that there was a need for an international organization which would work with disabled people living in poverty and help build the capacity of disabled people’s organisations to demand equal opportunities. During his eleven years at Action on Disability and Development Chris desperately tried to persuade the trustees to include mentally ill people in the program but the trustees wanted to focus solely on physical disabilities.
In 1996 Chris left Action on Disability and Development to join Practical Action as their Chief Executive. For the first time in his professional career Chris decided to direct an organization that he had not founded. He was drawn to Practical Action because of its innovative use of technology in tackling poverty in developing countries. During his time, Chris grew the organization’s budget from £8 to £13 million (US$13.3 to $21.5 million) and shifted the organization’s management from the developed to the developing world. After only four years as Chief Executive, Chris decided to leave the comfort and safety of Practical Action to realize his vision of supporting and empowering the mentally ill overseas. In 1999 he started from scratch, yet again, to found BasicNeeds.
Over the course of his career Chris has played a phenomenally active role in the third sector. As well as founding three COs he has acted as a trustee for a number of others including the Ashden Awards for Sustainable Energy, the Impetus Trust, and the Leaders Quest Foundation. In 2000 he was awarded an MBE by Her Majesty for services to disability both in the U.K. and internationally. In 2013 Chris received the Skoll Award for Social Entrepreneurship.