Reimagining Mental Health: The Global Turn Toward Rights-Based Community Care

The World Bank’s Innovations in Mental Health Services Delivery report, authored by renowned Italian psychiatrist Roberto Mezzina, is a landmark contribution to the global mental health discourse. Drawing on insights from leading research institutions such as the Lisbon Institute of Global Mental Health, Nova University of Lisbon, and the Universal Health Monitor in Washington, DC, the report maps the successes and struggles of countries pursuing rights-based, community-centered mental health care. Through a detailed synthesis of global reforms, it makes the case that traditional psychiatric institutions are not only outdated but actively obstruct the dignity, empowerment, and full inclusion of people with mental health conditions.

At the core of the paper is the process of deinstitutionalization (DI), which Mezzina stresses is not just about closing hospital doors but dismantling the institutional mindset and replacing it with holistic, community-rooted care. Many LMICs still channel the majority of mental health funding into psychiatric hospitals, despite their often abusive, ineffective, and socially isolating environments. In contrast, successful DI involves creating alternative systems that promote housing, employment, social inclusion, and human rights, all while embedding care within daily life rather than sequestering it behind institutional walls.

Trieste, Belgium, and Brazil: Case Studies in Innovation

Mezzina presents compelling case studies to show that transforming mental health care is possible. Italy’s Trieste model leads the way: by closing its psychiatric hospital in the late 1970s and developing 24-hour community mental health centers (CMHCs), Trieste has become a global benchmark. These centers operate under open-door principles, with no restraint, and strong community integration. They offer services ranging from crisis care to rehabilitation and social reintegration, and at a fraction of the cost of traditional hospital-based systems, just 37 percent, according to the report.

Belgium, through its network-based reform, took a different route by freezing thousands of psychiatric hospital beds and reallocating resources to mobile community mental health teams. This shift was enabled by a unique legal reform and strong strategic coordination across local stakeholders. Meanwhile, Brazil’s approach, rooted in cultural and community contexts, utilizes social cooperatives and community treatment centers to facilitate inclusion, particularly in underserved urban areas. Although each of these models has unique strengths, they share a common ethos: moving beyond the medicalized, custodial model toward one that sees individuals as citizens, not patients.

Stigma, Empowerment, and the Power of Peer Support

Stigma remains a formidable barrier to mental health care globally, reinforcing marginalization and undermining recovery. The report highlights the importance of empowering individuals with lived experience to become active participants in their own care and in shaping services. Only 16 percent of countries report mechanisms for such involvement, according to the WHO. Peer support programs, recovery colleges, and initiatives like Open Dialogue and the Hearing Voices movement are celebrated for their transformative potential. Box 6.1 in the report describes several of these programs, including crisis houses and recovery communities, which redefine the nature of mental health support.

The evidence on clinical outcomes is mixed but promising. Peer support has shown strong correlations with improvements in self-efficacy, social inclusion, and hope, if not always in symptom reduction. Programs such as Individual Placement and Support (IPS) demonstrate the critical role of employment in recovery, helping individuals with mental illness find and retain competitive jobs. Moreover, supported housing models, such as Housing First, provide stable living conditions unlinked to treatment compliance, respecting autonomy and encouraging reintegration.

COVID-19 and the Digital Frontier of Care

The COVID-19 pandemic, as Mezzina notes, exposed the deep fault lines in global mental health systems while accelerating innovation. Vulnerable groups, women, youth, older adults, and frontline workers faced worsened outcomes due to social isolation, economic stress, and disrupted services. But necessity bred innovation. Telehealth, digital mental health apps, and virtual community support flourished. Programs like the WHO’s Step-by-Step mobile app, based on evidence-based problem-solving therapy, became lifelines in countries with limited mental health infrastructure.

However, the report tempers optimism with caution. Digital mental health services can exacerbate exclusion for those without reliable internet or devices, and in some cases, overuse of screens may itself become detrimental to mental well-being. The report calls for regulation, data privacy safeguards, and a balance between in-person and digital approaches. Above all, digital tools should complement, not replace, the community bonds and human connection vital to mental health recovery.

A Call for a Paradigm Shift in Policy and Practice

The report concludes with a strong call to action: it is time to reject the custodial model of mental health and embrace a transformative, community-based vision rooted in human rights. Community mental health services, as outlined in Table 9.1, should adhere to seven core principles: ethics and evidence, proximity, globality, coproduction, non-coercion, integration, and de-institutionalization. These principles shift the paradigm from care as confinement to care as empowerment and participation.

Mezzina warns that partial reforms, those that maintain institutions while adding community elements, risk creating parallel systems and wasting resources. True transformation demands legislative change, strong political will, and above all, collaboration between users, professionals, civil society, and governments. The paper aligns closely with the WHO’s Transforming Mental Health for All report (2022), which urges countries to redesign services around rights, dignity, and equity.

The study is not just a technical roadmap; it’s a moral manifesto. It argues that community mental health is not an aspirational ideal but a viable, cost-effective, and humane solution to one of the most pressing challenges of our time. The question it leaves us with is both urgent and unambiguous: if not now, when?