So I'll quickly sort of take you through how the Bunim got to where we are today.
So it's essentially a story of the Banyan that I'll be presenting today and
perhaps talk about the three main programmatic areas of work off the ground.
That's what I'll be doing. So a little bit about the Banyan. We essentially are a non-profit organisation established in 1993.
We work at the intersection of homelessness, poverty and mental health issues.
To give you a background about why what we call as this nexus between homelessness,
poverty and mental health, there's not social causation and social drift.
So people from low income backgrounds, people who face social disadvantage and childhood adversities at a higher risk for serious mental disorders.
And at the same time, you also see the people who experience serious mental disorders often descend into homelessness and further poverty.
So that's the intersection. That way we are working in that a variety of studies that sort of establish this relationship even at the Banyan,
when we have examined our clients who've had histories of homelessness versus those who have not had histories of homelessness in the Indian context,
cost is a very important determinant of social determinants of health, and we find significant cost related differences.
So there are differences in between who ends up homeless on account of mental
health issues and who doesn't end up homeless on account of mental health issues. And clearly, it's not just a symptomatic incidence.
A lot of people will sort of assume and say that people are ending up homeless on the streets because their symptoms are not treated,
and therefore they are ending up homeless on the streets.
But what we have found in our experience is that irrespective of that history of treatment, we've analysed our data and we've seen that if you come,
if you inherit certain social disadvantages, you inherit liabilities associated, which include homelessness.
So that's the context in which we work and in the Indian scenario.
Typically in most cities in India,
you will find that the only options for a person who has a mental health issue and is and is homeless is essentially you get into a custodial
institution like a psychiatric facility or you get into beggars homes because homelessness is sort of criminalised in India in a variety of acts.
So we began in 1993, when the Bunin began in 1993.
It began as a very humanistic response from the invasion of Iraq to founders.
They found a woman with a mental health issue who was homeless on the streets of Chennai.
And in the process of trying to do something for her, they figured out that there were only no options for such women.
They admitted her to an NGO, and after a week when they went for follow up, they found that she was nowhere to be found.
So and in this context, they also found that in the next six months, wherever they went, they could only see homeless women with mental health issues.
I think it sort of got embedded. That experience got embedded and they decided we need to do something.
At that point of time, there were 22 or 23 women, very idealistic.
They said that how many such women can really be dead in the city of Chennai, perhaps that are only 30?
Such people will rent for three bedroom house, which is the house that you see over there.
1993 we rent a three bedroom house.
We are going to live for life with the 30 women that we rescue, and that's literally the idea that they started off with within a year.
We were at 70 in that house, we were at 70, and that's when they that it's not a small issue,
it's much larger and it's much more broader than what they initially thought of it as.
Another misconception, which they started off with which a lot of people continue to hold,
is that people with mental health issues who are ending up homeless are abandoned by their families.
People don't want to accept people with mental health issues and that abandoned. That's not the story that they found, at least in the initial years.
A lot of a lot of people said, Look, I wandered away from my family for variety of reasons, but I need to get back.
I have children. I need to get back to. I had a life before I used to work on this,
and this feels I need to get back to the job so people want to return to the kind of life that they had prior to it being disrupted.
And we started off doing reintegration. So of course, you know, somebody comes in, we offer crisis intervention services.
We take them through the entire range of psychiatric and medical care required.
Much of our population comes with concurrent physical health issues that range from tuberculosis to fractures to many skin related disorders.
So we take them through that. We take them through psychological therapies that are necessary.
We take them through a lot of social care interventions that are sort of establishing a bank account or whether it is in terms of,
you know, having access to the kind of clothes that they want. So a whole range of social care interventions right up to where do I want to go now?
So about 90 days is what women spend in office currently, and after a period of 90 days, the majority of them return back to their family.
So we started off doing familial reintegration, and this facility eventually grew into a much.
Larger psychiatric nursing home that you see, it's it's it's a licenced psychiatric nursing home for homeless women with mental health issues where
we engage in a systematic process of from emergency care to how do you go back to the community?
And it's not always necessarily typical. So it's not that everybody wants to go back to families.
Some people return back to the homeless communities that they had established while they were homeless.
So drugs that are the destruction of people who do want to sort of maybe they get back
into commercial sex work if that's what they were doing earlier and we allow for that,
but essentially to sort of explore, where does this person want to go from here and allowing them to return to the community
in the ways that they want to and providing them with continued care and aftercare?
Stay distraught so they don't get back into the homelessness trajectory again.
So that's our first intervention. That's the ICRC, what we call the emergency care and recovery centre.
Much of the learning that we've had over the many years through consultations
that we've had with many of our service users who are also part of the system.
About 25 percent of the banding staff work force are people who have a mental health issue, several of them also with histories of homelessness.
Is that when you when you when you talk of hospital based care in psychiatry,
it's very important to focus on quality and quantity starts right from the very basics of having privacy and dignity in
your making process to having the kind of food that you want to having access to kind of the clothing that you want.
And hospital is like a community forum, any user led initiative.
So we have a coffee, we have a we have people selling fish outside, we have a vegetable shop.
There's not there's nothing like this is what skills development needs to look look like.
I mean, in India, at least when you when you talk of work and engagement options for people have mental health issues,
it sort of descends into these sheltered workshops that people are put into.
We don't operate that way. People walk across reception, they work on research, they work and they don't really work and housekeeping.
They work in the kitchen. All parts of the hospital are part of the community and they work across.
So that's that's one very important approach that we have developed.
About three quarters of people who have come in contact with abandon have gone back.
40 percent are engaged in some kind of full-time or paid employment full time or part time.
And very recently, what we've been able to do after about 25 26 years of 25 years of work.
Actually,
last of this happen where the model that we have created off from crisis intervention to the integration of people with mental health issues,
homeless people with mental health issues. We've integrated it as part of the public health system itself.
So these are not standalone centres. The National Health Commission, the government of thumb, are not the run.
District hospitals are not public hospitals that cater to every health need and as part of those hospitals itself,
about 30 to 50 beds in seven hospitals. Now actually we've been able to do.
We started off with Ffion, but right now it's seven and we have a technical partners.
It's completely funded by the state, and we only offer the process of how do you go about doing what we've done?
So that's essentially the impact of ECAC. But what happens? What we also realised is that not everybody goes back home.
By the time we had sort of moved from a small facility to a larger facility at one point of time in our own test.
What do you call it was well-meaning. We wanted to reach out to every person in need.
We expanded a lot and the hospital cater to almost 400 people at one point of time.
But when we had discussions again with our users and when we sort of also looked at some of our outcomes, we realised that quantity was suffering.
We also realised that the rate at which people sort of went back home was also decreasing, and not everybody could necessarily go back home.
So we had a small portion of people who didn't go back to their family,
who don't get into independent employment arrangements, didn't get into homes on their own by themselves.
So there was a small percentage, and typically most of them had high support needs.
So these are people who are on clinical terms. You typically say that they have refractory symptoms.
So at that point of time, we decided that this is not the way that anybody should be spending their life,
irrespective of whether you know you get well or you do not get when in very clinical terms,
everybody should be offered the opportunity to live in the community as part of regular neighbourhoods just as any of us do,
and we offer the relevant supports to pursue the lives of their own choosing.
So we began home again in response to that particular realisation. So what are we doing home again?
And this is this is a typical house, but people may not necessarily live as part of groups that are also families
where we where we support them through just personal assistant services alone.
So essentially, it's a group of people who come together and say that I want to live as part
of the community and we enable those rehousing housing options along with.
Right or off site personnel assisting,
depending on the support need for each person and the support needs can be for some person, it could just be caring for myself.
But for some people it could be that I have been in the hospital for a very long time and I need to learn how to use public transport.
So it is about assisting them with that and that learning process. So it's diverse.
So each person gets a very bespoke plan based on the kind of support need to be have.
And the idea is that they get integrated into the community. So these are homes that we take in regular neighbourhoods.
We are very conscious about the kind of neighbourhoods that we take because they need to be good environments,
environments that you and I would also choose to live in homes that you and I would also choose to live here.
So that's home again and home again was evaluated in two phases as an on randomised controlled trial.
What we found through the research is that there are substantive community integration gains.
We participate not just more in their household, not just more in terms of getting back to work,
but we also saw that many of them had established a large amount of social networks in the neighbourhoods that they were living in.
And these were these are people remember who had supposedly had lived in the hospital for one year or more.
And I, you know, have essentially labelled as people who had high clinical needs.
And we also found that it does a fraction of what it costs to keep them lifelong in an institution.
So it's just half of what it costs to just stay even in our own institutional facility.
Home again is something that we've replicated along with the government of Canada and my Rashtra across five state-run psychiatric hospitals.
So we are working with a non-state population in these hospitals. Some of them have been incarcerated.
I call it incarceration, although incarceration, they use it typically in relation to jails.
I call it incarceration because they are no different. If you look at most of the mental hospitals in India, they're really no different.
So we have replicated and 70 people have gone back to homes of their own choosing.
And like I said, it's flexible. So we don't necessarily see that the only way the Home Home again will work is that four or five,
if you get together and you and we need and you need to stay as a unit,
we've also supported mothers who wanted to as know with their children, for instance,
or families who have not found the means to stabilise themselves than basic income transfers along with personalised support.
Do they get to a point where they can live independently?
So it works a bit flexibly, so people can also direct and purchase their own kind of supports the way they need it?
So that's home again. But when I wrote around two thousand four to 2020,
we engaged a lot of questions of why are people ending up homeless and why are people getting also into this long term institutional trajectory?
What's what's happening over there?
And I think in in the early days when we started sort of examining this issue, it was more related to, you know, how everybody thinks of it.
I mean, they're going back to very remote rural areas. Many of our clients, there's no access to care and because there's no access to care.
They are ending up homeless.
But like I said when I began the presentation, the more we sort of spoke to our constituency, the more that we sort of analysed our own data.
And to quantitatively, when we put the two together, clearly we saw that it was more social disadvantage.
So many of the clients that we have actually reintegrated, who had histories of homelessness had access.
The majority had access to care, but the it hadn't worked, so they had sought the psychiatrist.
It is not about repealing or any of the other things that people typically talk about.
So we said, What can we do about it? Can we develop a paradigm where you integrate?
You integrate health services, mental health services, along with social care services,
typical mental health services in A. In a very clinical sense, which is about,
you know, you approach your approach in an outpatient setting and you know,
you receive a diagnosis, you get medication and go back, but can be expanded to sort of see that.
Can we look at this person and this household holistically and try and understand what are those kind of factors that
are engaged in perpetuating this mental health issue or what could be engaged in the recovery trajectory as well,
because those produce differences in the kind of lives that people get to experience for themselves.
And this could be gender based. This could be caste based. So we started Mahlum in Ireland.
What we do is that we recruit people from the village villages that we work and we work with about a one million population across three states.
And we have identified catchment areas where we recruit people and they are trained essentially to sort of identify somebody in
psychosocial distress to be able to formulate whether this person will require clinical care if Yasser Arafat up to an outpatient clinic.
But as a standard, essentially along with the block level social worker, have plans in place which involve both house home based.
In fact, for problem-solving and facilitation of social entitlements through both state as well as non-state social get resources,
that's essentially Nala and with Nala, we have not been able to crack.
I should say the the social care aspects of it as well as we would have liked to be still trying to work around that,
but we are able to increase, I would say, absolute reach of the number of people who get into the necessary kind of care.
So at least 10000 people have enrolled and most of the people with serious mental disorders from within the catchment areas that we have,
we are working in with a period of about three or four years. They typically get into get.
We worked predominantly with seniors mental disorders because of our motivation to get
into community mental health is to do with the fact that we want to reduce homelessness, so we focus more heavily on that site.
About 35 to 40 percent are going back to work.
It is a little higher than that already in the urban, it's much lesser getting back into work as much lower.
We also work very actively with the children who are living with parental mental illness, as well as at-risk populations,
because most of them mental health issues that we speak about actually manifest before the age of 14.
And so we work with at-risk children and we offer personalised support as well.
I'll talk about a brief story, and this is one of my favourite stories is an exemplar,
so not a typical trajectory that everybody takes, but it's a great story to sort of see the kind of possibilities.
You know, one can have the right kind of support. So Emily and Jacqueline came to us almost, I would say, little over 13, 14 years ago.
Jacqueline is a trained nurse. She developed a bipolar disorder.
She had a bad marriage, and she ended up.
She actually ended up sort of closed off in a small room in her village,
where for news to be passed down to her from, you know, a small hole just under the door.
And that's how she was living for a few years. They did access treatment and she got a little better.
But also that episode was that episode when she tried to seek work because the reputation was sort of established.
Even though she had gotten a little better every way that she went to work as a nurse, she was rejected.
She finally came to and looked for jobs, and Jenny ended up homeless because nobody was willing to hire a home.
So that's how Jacquelin came to us, and slowly as she came to us, she recovered, she, you know, got well.
She started working as a nurse with us and Emily, her sister came in search of Jacqueline and again ended up with us.
Both of them said that we want to sort of do what you what you are doing in our village.
They live in a small village of a city called Touchin Dominant, and they said that,
you know, we'd like to get back and we'd like to do what you're doing. So we have no mental health professionals located at that site.
Jacqueline and Emily are, of course, no. One source, but the idea is that they've become a social enterprise,
independently registered organisation by themselves, the support six homes and 30 women across these six homes.
And if brought the whole community around to the community where they work,
a lot of women left without spousal support affected by drought have been employed in the design of this project, and they've done it.
So far, there's no social worker, there's no psychologist or any of those typical human resource structures.
And this is the kind of trajectory that we'd like to aspire for several more people.
There are many examples like this. So what have we learnt through in interventions expedience?
I think the first most important learning for us is that when we think of health systems and health systems reform and responses,
the typical thing which a lot of governments at least do is that you throw money at building or infrastructure or you throw money at.
Let's increase service access forms or you see that let's increase the human resources.
But what we feel is very important to build in mental health responses is adaptive capacity.
That is, how are you going to engage in a dialogue with people that you're working with?
Can they also become part of the work that you're doing?
Can they take on leadership positions and can you reflect upon what's happening continuously on the ground?
And can you therefore innovate? Because that's how the brand name has been able to innovate,
whether it's in terms of strengthening the quality of care that we offer or in coming up with new innovations,
it has not come agnostic of engagement with our own constituency.
So can health systems be adaptive rather than working in a very top-down hierarchical fashion because you can throw money at infrastructure?
We've had several efforts to upgrade our psychiatric hospitals, are centres of excellence and given a lot of money,
but they may not necessarily produce the kind of outcomes that we are looking for.
The second most important takeaway for us in terms of mental health system responses is that you need services that are integrated.
And I know this may seem very clichéd,
but this is the most important thing that we have learnt that people's mental health problems are not on are not just biological right.
And I hope everybody in the room agrees with me. And there are there are social aspects to it which need to be considered right from when
an individual comes and you formulate that case and you formulate a care plan for them.
So right from then on, it needs to be acknowledged and they cannot be.
I mean, I'm already burdened by double jeopardy, right? Not triple jeopardy.
Don't make me go navigate to different departments, establish my eligibility, prove that I am poor.
Therefore, I should receive social assistance. Don't do that.
Health systems need to do a lot more in terms of offering an integrated service experience for users,
especially those who come from backgrounds of social disadvantage.
So that's that's the second most important takeaway card.
Most important thing is that I think when we chase outcomes and not and oftentimes when we even even at the Banyan,
when we do a systems W, we look at things like, you know, that used in patient days reduce dropout rate a whole variety of outcomes.
But eventually what holds meaning in people's lives, it's in fact not even symptom reduction.
What we found with our users is that I'd like to get back to work. I used to have this life before I used to do all these things.
I need to get back right. So then health systems offer.
For diverse aspirations, can health systems respond and offer necessary services?
So those are some of the important takeaways we've heard from the Bunyan's experience.
The bigger picture because we're talking about mental health in India and this is like, you know,
some of the goals that we're sort of looking Patrice as an organisation and along with many of us service users.
So the first is that we want to sort of understand the distress of social distress that occurs alongside mental ill health.
How do we sort of alleviate that? And what are the kind of arrangements that can be made to have collaborative delivery?
The second thing that we want to work on is that, of course, prognostic value of early intervention has been well-established.
But can we interconnect these clinical pathways with very grassroots kind of engagement, the kind that I was also talking about earlier today?
Human resource structure. So I think task shifting is a big it's a big word, but we think that we need to move beyond that.
There are people with first hand experiences. There are people with firsthand experiences who come from particular kind of socioeconomic locations,
and it's very important that we move towards a therapeutic community.
It's about anchored by them because it's their experience that can really drive those sorts of interventions.
Look at introducing new mental health care.
I mean, most of the money in India currently, I know, goes towards the for the sustaining the for the three mental hospitals.
And then, of course, a variety of, you know, experiences and quality, of course, differs from one to another.
And we cannot sort of put all of them into one monolithic description, but I certainly agree with.
But do we not? Does it not, you know, anger us that of mental health care in many parts are not changed despite years and years of reform.
And you know, all these committee reports, right from 1946 onwards, we've been talking about the same thing.
So how can we move beyond or do we need institutional care?
Or do we not need institutional care to actually be talking about, OK, what's the size of an institution needs to be?
Can we look at discourse around what should be the best environment in this particular institution?
And can we re-engineer the social architecture so that it becomes a more person centred recovery kind of a space?
So that's what I leave you with this sense that any questions please asked.