1 00:00:07,980 --> 00:00:15,510 So I'll quickly sort of take you through how the Bunim got to where we are today. 2 00:00:15,510 --> 00:00:19,830 So it's essentially a story of the Banyan that I'll be presenting today and 3 00:00:19,830 --> 00:00:25,530 perhaps talk about the three main programmatic areas of work off the ground. 4 00:00:25,530 --> 00:00:31,780 That's what I'll be doing. So a little bit about the Banyan. We essentially are a non-profit organisation established in 1993. 5 00:00:31,780 --> 00:00:37,680 We work at the intersection of homelessness, poverty and mental health issues. 6 00:00:37,680 --> 00:00:42,750 To give you a background about why what we call as this nexus between homelessness, 7 00:00:42,750 --> 00:00:46,890 poverty and mental health, there's not social causation and social drift. 8 00:00:46,890 --> 00:00:56,580 So people from low income backgrounds, people who face social disadvantage and childhood adversities at a higher risk for serious mental disorders. 9 00:00:56,580 --> 00:01:04,740 And at the same time, you also see the people who experience serious mental disorders often descend into homelessness and further poverty. 10 00:01:04,740 --> 00:01:13,410 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, 11 00:01:13,410 --> 00:01:20,550 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, 12 00:01:20,550 --> 00:01:27,390 cost is a very important determinant of social determinants of health, and we find significant cost related differences. 13 00:01:27,390 --> 00:01:30,840 So there are differences in between who ends up homeless on account of mental 14 00:01:30,840 --> 00:01:36,850 health issues and who doesn't end up homeless on account of mental health issues. And clearly, it's not just a symptomatic incidence. 15 00:01:36,850 --> 00:01:43,620 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, 16 00:01:43,620 --> 00:01:46,140 and therefore they are ending up homeless on the streets. 17 00:01:46,140 --> 00:01:53,490 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, 18 00:01:53,490 --> 00:01:59,850 if you inherit certain social disadvantages, you inherit liabilities associated, which include homelessness. 19 00:01:59,850 --> 00:02:04,830 So that's the context in which we work and in the Indian scenario. 20 00:02:04,830 --> 00:02:07,530 Typically in most cities in India, 21 00:02:07,530 --> 00:02:15,900 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 22 00:02:15,900 --> 00:02:25,800 institution like a psychiatric facility or you get into beggars homes because homelessness is sort of criminalised in India in a variety of acts. 23 00:02:25,800 --> 00:02:29,790 So we began in 1993, when the Bunin began in 1993. 24 00:02:29,790 --> 00:02:33,480 It began as a very humanistic response from the invasion of Iraq to founders. 25 00:02:33,480 --> 00:02:38,820 They found a woman with a mental health issue who was homeless on the streets of Chennai. 26 00:02:38,820 --> 00:02:44,550 And in the process of trying to do something for her, they figured out that there were only no options for such women. 27 00:02:44,550 --> 00:02:52,320 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. 28 00:02:52,320 --> 00:03:00,540 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. 29 00:03:00,540 --> 00:03:06,180 I think it sort of got embedded. That experience got embedded and they decided we need to do something. 30 00:03:06,180 --> 00:03:09,000 At that point of time, there were 22 or 23 women, very idealistic. 31 00:03:09,000 --> 00:03:13,140 They said that how many such women can really be dead in the city of Chennai, perhaps that are only 30? 32 00:03:13,140 --> 00:03:18,180 Such people will rent for three bedroom house, which is the house that you see over there. 33 00:03:18,180 --> 00:03:20,640 1993 we rent a three bedroom house. 34 00:03:20,640 --> 00:03:28,050 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. 35 00:03:28,050 --> 00:03:33,360 We were at 70 in that house, we were at 70, and that's when they that it's not a small issue, 36 00:03:33,360 --> 00:03:39,660 it's much larger and it's much more broader than what they initially thought of it as. 37 00:03:39,660 --> 00:03:43,920 Another misconception, which they started off with which a lot of people continue to hold, 38 00:03:43,920 --> 00:03:49,990 is that people with mental health issues who are ending up homeless are abandoned by their families. 39 00:03:49,990 --> 00:03:55,920 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. 40 00:03:55,920 --> 00:04:02,520 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. 41 00:04:02,520 --> 00:04:06,420 I have children. I need to get back to. I had a life before I used to work on this, 42 00:04:06,420 --> 00:04:14,100 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. 43 00:04:14,100 --> 00:04:20,640 And we started off doing reintegration. So of course, you know, somebody comes in, we offer crisis intervention services. 44 00:04:20,640 --> 00:04:25,050 We take them through the entire range of psychiatric and medical care required. 45 00:04:25,050 --> 00:04:34,350 Much of our population comes with concurrent physical health issues that range from tuberculosis to fractures to many skin related disorders. 46 00:04:34,350 --> 00:04:37,740 So we take them through that. We take them through psychological therapies that are necessary. 47 00:04:37,740 --> 00:04:44,820 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, 48 00:04:44,820 --> 00:04:53,550 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? 49 00:04:53,550 --> 00:05:01,410 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. 50 00:05:01,410 --> 00:05:07,650 So we started off doing familial reintegration, and this facility eventually grew into a much. 51 00:05:07,650 --> 00:05:16,710 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 52 00:05:16,710 --> 00:05:23,070 we engage in a systematic process of from emergency care to how do you go back to the community? 53 00:05:23,070 --> 00:05:27,180 And it's not always necessarily typical. So it's not that everybody wants to go back to families. 54 00:05:27,180 --> 00:05:32,430 Some people return back to the homeless communities that they had established while they were homeless. 55 00:05:32,430 --> 00:05:36,960 So drugs that are the destruction of people who do want to sort of maybe they get back 56 00:05:36,960 --> 00:05:40,470 into commercial sex work if that's what they were doing earlier and we allow for that, 57 00:05:40,470 --> 00:05:46,290 but essentially to sort of explore, where does this person want to go from here and allowing them to return to the community 58 00:05:46,290 --> 00:05:50,790 in the ways that they want to and providing them with continued care and aftercare? 59 00:05:50,790 --> 00:05:54,600 Stay distraught so they don't get back into the homelessness trajectory again. 60 00:05:54,600 --> 00:06:01,110 So that's our first intervention. That's the ICRC, what we call the emergency care and recovery centre. 61 00:06:01,110 --> 00:06:06,210 Much of the learning that we've had over the many years through consultations 62 00:06:06,210 --> 00:06:09,240 that we've had with many of our service users who are also part of the system. 63 00:06:09,240 --> 00:06:16,410 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. 64 00:06:16,410 --> 00:06:21,270 Is that when you when you when you talk of hospital based care in psychiatry, 65 00:06:21,270 --> 00:06:28,410 it's very important to focus on quality and quantity starts right from the very basics of having privacy and dignity in 66 00:06:28,410 --> 00:06:35,400 your making process to having the kind of food that you want to having access to kind of the clothing that you want. 67 00:06:35,400 --> 00:06:38,400 And hospital is like a community forum, any user led initiative. 68 00:06:38,400 --> 00:06:44,520 So we have a coffee, we have a we have people selling fish outside, we have a vegetable shop. 69 00:06:44,520 --> 00:06:48,450 There's not there's nothing like this is what skills development needs to look look like. 70 00:06:48,450 --> 00:06:54,330 I mean, in India, at least when you when you talk of work and engagement options for people have mental health issues, 71 00:06:54,330 --> 00:06:57,840 it sort of descends into these sheltered workshops that people are put into. 72 00:06:57,840 --> 00:07:04,140 We don't operate that way. People walk across reception, they work on research, they work and they don't really work and housekeeping. 73 00:07:04,140 --> 00:07:08,550 They work in the kitchen. All parts of the hospital are part of the community and they work across. 74 00:07:08,550 --> 00:07:14,370 So that's that's one very important approach that we have developed. 75 00:07:14,370 --> 00:07:20,430 About three quarters of people who have come in contact with abandon have gone back. 76 00:07:20,430 --> 00:07:27,240 40 percent are engaged in some kind of full-time or paid employment full time or part time. 77 00:07:27,240 --> 00:07:32,940 And very recently, what we've been able to do after about 25 26 years of 25 years of work. 78 00:07:32,940 --> 00:07:33,210 Actually, 79 00:07:33,210 --> 00:07:41,160 last of this happen where the model that we have created off from crisis intervention to the integration of people with mental health issues, 80 00:07:41,160 --> 00:07:45,390 homeless people with mental health issues. We've integrated it as part of the public health system itself. 81 00:07:45,390 --> 00:07:51,960 So these are not standalone centres. The National Health Commission, the government of thumb, are not the run. 82 00:07:51,960 --> 00:07:57,000 District hospitals are not public hospitals that cater to every health need and as part of those hospitals itself, 83 00:07:57,000 --> 00:08:01,440 about 30 to 50 beds in seven hospitals. Now actually we've been able to do. 84 00:08:01,440 --> 00:08:04,920 We started off with Ffion, but right now it's seven and we have a technical partners. 85 00:08:04,920 --> 00:08:13,560 It's completely funded by the state, and we only offer the process of how do you go about doing what we've done? 86 00:08:13,560 --> 00:08:19,440 So that's essentially the impact of ECAC. But what happens? What we also realised is that not everybody goes back home. 87 00:08:19,440 --> 00:08:28,200 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. 88 00:08:28,200 --> 00:08:32,280 What do you call it was well-meaning. We wanted to reach out to every person in need. 89 00:08:32,280 --> 00:08:37,620 We expanded a lot and the hospital cater to almost 400 people at one point of time. 90 00:08:37,620 --> 00:08:44,850 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. 91 00:08:44,850 --> 00:08:52,110 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. 92 00:08:52,110 --> 00:08:55,560 So we had a small portion of people who didn't go back to their family, 93 00:08:55,560 --> 00:09:02,040 who don't get into independent employment arrangements, didn't get into homes on their own by themselves. 94 00:09:02,040 --> 00:09:07,920 So there was a small percentage, and typically most of them had high support needs. 95 00:09:07,920 --> 00:09:13,770 So these are people who are on clinical terms. You typically say that they have refractory symptoms. 96 00:09:13,770 --> 00:09:19,350 So at that point of time, we decided that this is not the way that anybody should be spending their life, 97 00:09:19,350 --> 00:09:27,180 irrespective of whether you know you get well or you do not get when in very clinical terms, 98 00:09:27,180 --> 00:09:34,680 everybody should be offered the opportunity to live in the community as part of regular neighbourhoods just as any of us do, 99 00:09:34,680 --> 00:09:38,490 and we offer the relevant supports to pursue the lives of their own choosing. 100 00:09:38,490 --> 00:09:43,740 So we began home again in response to that particular realisation. So what are we doing home again? 101 00:09:43,740 --> 00:09:52,740 And this is this is a typical house, but people may not necessarily live as part of groups that are also families 102 00:09:52,740 --> 00:09:57,090 where we where we support them through just personal assistant services alone. 103 00:09:57,090 --> 00:10:01,260 So essentially, it's a group of people who come together and say that I want to live as part 104 00:10:01,260 --> 00:10:07,490 of the community and we enable those rehousing housing options along with. 105 00:10:07,490 --> 00:10:09,500 Right or off site personnel assisting, 106 00:10:09,500 --> 00:10:15,440 depending on the support need for each person and the support needs can be for some person, it could just be caring for myself. 107 00:10:15,440 --> 00:10:21,260 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. 108 00:10:21,260 --> 00:10:25,580 So it is about assisting them with that and that learning process. So it's diverse. 109 00:10:25,580 --> 00:10:30,890 So each person gets a very bespoke plan based on the kind of support need to be have. 110 00:10:30,890 --> 00:10:37,310 And the idea is that they get integrated into the community. So these are homes that we take in regular neighbourhoods. 111 00:10:37,310 --> 00:10:42,710 We are very conscious about the kind of neighbourhoods that we take because they need to be good environments, 112 00:10:42,710 --> 00:10:47,570 environments that you and I would also choose to live in homes that you and I would also choose to live here. 113 00:10:47,570 --> 00:10:56,840 So that's home again and home again was evaluated in two phases as an on randomised controlled trial. 114 00:10:56,840 --> 00:11:01,760 What we found through the research is that there are substantive community integration gains. 115 00:11:01,760 --> 00:11:06,980 We participate not just more in their household, not just more in terms of getting back to work, 116 00:11:06,980 --> 00:11:13,790 but we also saw that many of them had established a large amount of social networks in the neighbourhoods that they were living in. 117 00:11:13,790 --> 00:11:19,430 And these were these are people remember who had supposedly had lived in the hospital for one year or more. 118 00:11:19,430 --> 00:11:25,640 And I, you know, have essentially labelled as people who had high clinical needs. 119 00:11:25,640 --> 00:11:30,740 And we also found that it does a fraction of what it costs to keep them lifelong in an institution. 120 00:11:30,740 --> 00:11:35,360 So it's just half of what it costs to just stay even in our own institutional facility. 121 00:11:35,360 --> 00:11:43,890 Home again is something that we've replicated along with the government of Canada and my Rashtra across five state-run psychiatric hospitals. 122 00:11:43,890 --> 00:11:49,370 So we are working with a non-state population in these hospitals. Some of them have been incarcerated. 123 00:11:49,370 --> 00:11:54,620 I call it incarceration, although incarceration, they use it typically in relation to jails. 124 00:11:54,620 --> 00:12:01,670 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. 125 00:12:01,670 --> 00:12:10,430 So we have replicated and 70 people have gone back to homes of their own choosing. 126 00:12:10,430 --> 00:12:16,160 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, 127 00:12:16,160 --> 00:12:19,820 if you get together and you and we need and you need to stay as a unit, 128 00:12:19,820 --> 00:12:23,720 we've also supported mothers who wanted to as know with their children, for instance, 129 00:12:23,720 --> 00:12:34,590 or families who have not found the means to stabilise themselves than basic income transfers along with personalised support. 130 00:12:34,590 --> 00:12:37,010 Do they get to a point where they can live independently? 131 00:12:37,010 --> 00:12:43,160 So it works a bit flexibly, so people can also direct and purchase their own kind of supports the way they need it? 132 00:12:43,160 --> 00:12:49,680 So that's home again. But when I wrote around two thousand four to 2020, 133 00:12:49,680 --> 00:13:01,820 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? 134 00:13:01,820 --> 00:13:03,290 What's what's happening over there? 135 00:13:03,290 --> 00:13:12,530 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. 136 00:13:12,530 --> 00:13:18,770 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. 137 00:13:18,770 --> 00:13:19,850 They are ending up homeless. 138 00:13:19,850 --> 00:13:26,180 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. 139 00:13:26,180 --> 00:13:30,860 And to quantitatively, when we put the two together, clearly we saw that it was more social disadvantage. 140 00:13:30,860 --> 00:13:36,680 So many of the clients that we have actually reintegrated, who had histories of homelessness had access. 141 00:13:36,680 --> 00:13:41,180 The majority had access to care, but the it hadn't worked, so they had sought the psychiatrist. 142 00:13:41,180 --> 00:13:45,740 It is not about repealing or any of the other things that people typically talk about. 143 00:13:45,740 --> 00:13:50,910 So we said, What can we do about it? Can we develop a paradigm where you integrate? 144 00:13:50,910 --> 00:13:55,760 You integrate health services, mental health services, along with social care services, 145 00:13:55,760 --> 00:13:59,930 typical mental health services in A. In a very clinical sense, which is about, 146 00:13:59,930 --> 00:14:03,890 you know, you approach your approach in an outpatient setting and you know, 147 00:14:03,890 --> 00:14:08,360 you receive a diagnosis, you get medication and go back, but can be expanded to sort of see that. 148 00:14:08,360 --> 00:14:15,350 Can we look at this person and this household holistically and try and understand what are those kind of factors that 149 00:14:15,350 --> 00:14:22,220 are engaged in perpetuating this mental health issue or what could be engaged in the recovery trajectory as well, 150 00:14:22,220 --> 00:14:26,630 because those produce differences in the kind of lives that people get to experience for themselves. 151 00:14:26,630 --> 00:14:31,790 And this could be gender based. This could be caste based. So we started Mahlum in Ireland. 152 00:14:31,790 --> 00:14:42,470 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. 153 00:14:42,470 --> 00:14:49,280 And we have identified catchment areas where we recruit people and they are trained essentially to sort of identify somebody in 154 00:14:49,280 --> 00:14:58,160 psychosocial distress to be able to formulate whether this person will require clinical care if Yasser Arafat up to an outpatient clinic. 155 00:14:58,160 --> 00:15:07,450 But as a standard, essentially along with the block level social worker, have plans in place which involve both house home based. 156 00:15:07,450 --> 00:15:15,910 In fact, for problem-solving and facilitation of social entitlements through both state as well as non-state social get resources, 157 00:15:15,910 --> 00:15:22,090 that's essentially Nala and with Nala, we have not been able to crack. 158 00:15:22,090 --> 00:15:30,370 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, 159 00:15:30,370 --> 00:15:39,100 but we are able to increase, I would say, absolute reach of the number of people who get into the necessary kind of care. 160 00:15:39,100 --> 00:15:45,760 So at least 10000 people have enrolled and most of the people with serious mental disorders from within the catchment areas that we have, 161 00:15:45,760 --> 00:15:50,800 we are working in with a period of about three or four years. They typically get into get. 162 00:15:50,800 --> 00:15:55,780 We worked predominantly with seniors mental disorders because of our motivation to get 163 00:15:55,780 --> 00:16:01,480 into community mental health is to do with the fact that we want to reduce homelessness, so we focus more heavily on that site. 164 00:16:01,480 --> 00:16:03,700 About 35 to 40 percent are going back to work. 165 00:16:03,700 --> 00:16:12,670 It is a little higher than that already in the urban, it's much lesser getting back into work as much lower. 166 00:16:12,670 --> 00:16:20,350 We also work very actively with the children who are living with parental mental illness, as well as at-risk populations, 167 00:16:20,350 --> 00:16:26,190 because most of them mental health issues that we speak about actually manifest before the age of 14. 168 00:16:26,190 --> 00:16:30,880 And so we work with at-risk children and we offer personalised support as well. 169 00:16:30,880 --> 00:16:36,970 I'll talk about a brief story, and this is one of my favourite stories is an exemplar, 170 00:16:36,970 --> 00:16:43,870 so not a typical trajectory that everybody takes, but it's a great story to sort of see the kind of possibilities. 171 00:16:43,870 --> 00:16:52,150 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. 172 00:16:52,150 --> 00:16:56,920 Jacqueline is a trained nurse. She developed a bipolar disorder. 173 00:16:56,920 --> 00:17:01,330 She had a bad marriage, and she ended up. 174 00:17:01,330 --> 00:17:09,400 She actually ended up sort of closed off in a small room in her village, 175 00:17:09,400 --> 00:17:14,890 where for news to be passed down to her from, you know, a small hole just under the door. 176 00:17:14,890 --> 00:17:20,110 And that's how she was living for a few years. They did access treatment and she got a little better. 177 00:17:20,110 --> 00:17:26,290 But also that episode was that episode when she tried to seek work because the reputation was sort of established. 178 00:17:26,290 --> 00:17:31,510 Even though she had gotten a little better every way that she went to work as a nurse, she was rejected. 179 00:17:31,510 --> 00:17:37,940 She finally came to and looked for jobs, and Jenny ended up homeless because nobody was willing to hire a home. 180 00:17:37,940 --> 00:17:46,250 So that's how Jacquelin came to us, and slowly as she came to us, she recovered, she, you know, got well. 181 00:17:46,250 --> 00:17:53,300 She started working as a nurse with us and Emily, her sister came in search of Jacqueline and again ended up with us. 182 00:17:53,300 --> 00:17:59,000 Both of them said that we want to sort of do what you what you are doing in our village. 183 00:17:59,000 --> 00:18:05,240 They live in a small village of a city called Touchin Dominant, and they said that, 184 00:18:05,240 --> 00:18:12,290 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. 185 00:18:12,290 --> 00:18:18,560 Jacqueline and Emily are, of course, no. One source, but the idea is that they've become a social enterprise, 186 00:18:18,560 --> 00:18:26,360 independently registered organisation by themselves, the support six homes and 30 women across these six homes. 187 00:18:26,360 --> 00:18:30,740 And if brought the whole community around to the community where they work, 188 00:18:30,740 --> 00:18:37,970 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. 189 00:18:37,970 --> 00:18:46,430 So far, there's no social worker, there's no psychologist or any of those typical human resource structures. 190 00:18:46,430 --> 00:18:50,930 And this is the kind of trajectory that we'd like to aspire for several more people. 191 00:18:50,930 --> 00:18:58,230 There are many examples like this. So what have we learnt through in interventions expedience? 192 00:18:58,230 --> 00:19:05,960 I think the first most important learning for us is that when we think of health systems and health systems reform and responses, 193 00:19:05,960 --> 00:19:13,340 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. 194 00:19:13,340 --> 00:19:18,020 Let's increase service access forms or you see that let's increase the human resources. 195 00:19:18,020 --> 00:19:23,840 But what we feel is very important to build in mental health responses is adaptive capacity. 196 00:19:23,840 --> 00:19:27,750 That is, how are you going to engage in a dialogue with people that you're working with? 197 00:19:27,750 --> 00:19:30,500 Can they also become part of the work that you're doing? 198 00:19:30,500 --> 00:19:36,620 Can they take on leadership positions and can you reflect upon what's happening continuously on the ground? 199 00:19:36,620 --> 00:19:40,100 And can you therefore innovate? Because that's how the brand name has been able to innovate, 200 00:19:40,100 --> 00:19:44,900 whether it's in terms of strengthening the quality of care that we offer or in coming up with new innovations, 201 00:19:44,900 --> 00:19:48,560 it has not come agnostic of engagement with our own constituency. 202 00:19:48,560 --> 00:19:56,780 So can health systems be adaptive rather than working in a very top-down hierarchical fashion because you can throw money at infrastructure? 203 00:19:56,780 --> 00:20:03,260 We've had several efforts to upgrade our psychiatric hospitals, are centres of excellence and given a lot of money, 204 00:20:03,260 --> 00:20:07,230 but they may not necessarily produce the kind of outcomes that we are looking for. 205 00:20:07,230 --> 00:20:14,120 The second most important takeaway for us in terms of mental health system responses is that you need services that are integrated. 206 00:20:14,120 --> 00:20:16,040 And I know this may seem very clichéd, 207 00:20:16,040 --> 00:20:24,260 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. 208 00:20:24,260 --> 00:20:31,700 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 209 00:20:31,700 --> 00:20:36,110 an individual comes and you formulate that case and you formulate a care plan for them. 210 00:20:36,110 --> 00:20:39,710 So right from then on, it needs to be acknowledged and they cannot be. 211 00:20:39,710 --> 00:20:43,970 I mean, I'm already burdened by double jeopardy, right? Not triple jeopardy. 212 00:20:43,970 --> 00:20:49,700 Don't make me go navigate to different departments, establish my eligibility, prove that I am poor. 213 00:20:49,700 --> 00:20:52,520 Therefore, I should receive social assistance. Don't do that. 214 00:20:52,520 --> 00:20:57,620 Health systems need to do a lot more in terms of offering an integrated service experience for users, 215 00:20:57,620 --> 00:21:03,050 especially those who come from backgrounds of social disadvantage. 216 00:21:03,050 --> 00:21:06,800 So that's that's the second most important takeaway card. 217 00:21:06,800 --> 00:21:14,330 Most important thing is that I think when we chase outcomes and not and oftentimes when we even even at the Banyan, 218 00:21:14,330 --> 00:21:21,830 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. 219 00:21:21,830 --> 00:21:27,860 But eventually what holds meaning in people's lives, it's in fact not even symptom reduction. 220 00:21:27,860 --> 00:21:34,100 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. 221 00:21:34,100 --> 00:21:39,730 I need to get back right. So then health systems offer. 222 00:21:39,730 --> 00:21:46,330 For diverse aspirations, can health systems respond and offer necessary services? 223 00:21:46,330 --> 00:21:51,430 So those are some of the important takeaways we've heard from the Bunyan's experience. 224 00:21:51,430 --> 00:21:55,810 The bigger picture because we're talking about mental health in India and this is like, you know, 225 00:21:55,810 --> 00:22:03,610 some of the goals that we're sort of looking Patrice as an organisation and along with many of us service users. 226 00:22:03,610 --> 00:22:12,430 So the first is that we want to sort of understand the distress of social distress that occurs alongside mental ill health. 227 00:22:12,430 --> 00:22:19,120 How do we sort of alleviate that? And what are the kind of arrangements that can be made to have collaborative delivery? 228 00:22:19,120 --> 00:22:24,910 The second thing that we want to work on is that, of course, prognostic value of early intervention has been well-established. 229 00:22:24,910 --> 00:22:36,010 But can we interconnect these clinical pathways with very grassroots kind of engagement, the kind that I was also talking about earlier today? 230 00:22:36,010 --> 00:22:43,480 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. 231 00:22:43,480 --> 00:22:50,950 There are people with first hand experiences. There are people with firsthand experiences who come from particular kind of socioeconomic locations, 232 00:22:50,950 --> 00:22:55,570 and it's very important that we move towards a therapeutic community. 233 00:22:55,570 --> 00:23:02,890 It's about anchored by them because it's their experience that can really drive those sorts of interventions. 234 00:23:02,890 --> 00:23:04,780 Look at introducing new mental health care. 235 00:23:04,780 --> 00:23:12,460 I mean, most of the money in India currently, I know, goes towards the for the sustaining the for the three mental hospitals. 236 00:23:12,460 --> 00:23:20,860 And then, of course, a variety of, you know, experiences and quality, of course, differs from one to another. 237 00:23:20,860 --> 00:23:25,720 And we cannot sort of put all of them into one monolithic description, but I certainly agree with. 238 00:23:25,720 --> 00:23:37,150 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. 239 00:23:37,150 --> 00:23:42,160 And you know, all these committee reports, right from 1946 onwards, we've been talking about the same thing. 240 00:23:42,160 --> 00:23:46,570 So how can we move beyond or do we need institutional care? 241 00:23:46,570 --> 00:23:51,700 Or do we not need institutional care to actually be talking about, OK, what's the size of an institution needs to be? 242 00:23:51,700 --> 00:23:56,680 Can we look at discourse around what should be the best environment in this particular institution? 243 00:23:56,680 --> 00:24:01,840 And can we re-engineer the social architecture so that it becomes a more person centred recovery kind of a space? 244 00:24:01,840 --> 00:24:13,930 So that's what I leave you with this sense that any questions please asked.