For decades, the burden of mental health conditions has been one of public health’s most significant, yet neglected, challenges (1). Globally, mental health conditions accounted for an increase from 80.8 million disability-adjusted life years (DALYs) in 1990 to 125.3 million DALYs in 2019, representing a considerable proportion of the global disease burden (2). Mental health has emerged as a key public health priority in recent years, a recognition both challenged and accelerated by the COVID-19 pandemic. The pandemic did not create a mental health crisis (3); it merely illuminated it, exposing the fragility of our collective well-being to the world. This shared experience, and the greater recognition of the social determinants and significant implementation failure in mental health (4), has finally shifted mental health from the periphery to the centre of political discourse, creating a momentum that must be translated into sustainable action.
The forthcoming United Nations (UN) General Assembly High-Level Meeting (HLM) on the Prevention and Control of Noncommunicable Diseases (NCDs) and the Promotion of Mental Health presents a critical opportunity for global health governance. Over the last 15 years three HLMs have focused on NCDs, but this is a rare occasion of mental health being included at the core of such a meeting. This substantive policy discourse is pushing for a truer integration, building on previous uses of the language of “NCDs, including mental health conditions.” The central task of this HLM is therefore to transcend the cautious phrasing of its title and use this opportunity to formally embed mental health as an indivisible component of the global health agenda, thereby finally fulfilling the entirety of SDG Target 3.4: by 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.
Our expectations of what will result from the upcoming HLM need to be tempered by a dose of realism concerning the modest results of previous HLMs (5). The HLM model proved transformative for HIV/AIDS, partly because its devastating toll on young people spurred a powerful, focused global movement. Mental health shares this critical parallel with HIV/AIDS: its profound impact on youth, with up to 50% of mental health conditions having their onset before the age of 18 years (6). The far-reaching power of this demographic urgency is a strategic lesson the NCD agenda should leverage having recognised the importance of integrating mental health into its core concerns and its undeniable relevance to the discipline of public health (1).
The public health community must first dissect and confront three central paradoxes embedded within the emerging declaration to translate its non-binding political commitment into tangible progress. These are also building on this year’s UN Multi-Stakeholder Hearing that saw the strongest and broadest representation ever from advocates with lived experience of mental health conditions.
A welcome strength of the emerging HLM declaration is its shift towards concrete, measurable targets, such as reaching 150 million more people with mental health care and allocating at least 5% of health budgets to mental health. This is building on the recommendation of the 2018 Lancet Commission and the WHO Mental Health Atlas statistics that show that the average figure currently is less than 2% (7). While this specificity is a vital step towards accountability (and is far from confirmed and adopted), we must question if the ambition is sufficient. Is a 5% budget for an issue causing such a profound burden of disability truly transformative, or is it merely a symbolic start after decades of systemic neglect (8)?
The public health community must also address the “integration paradox” evident in the draft declaration. While the text champions an integrated approach, it sets a process target for mental health (access to care) while assigning outcome targets for NCD risk factors. This fragmentation fails to recognise the extensive progress in mental health surveillance (9). This paradox reveals an outdated approach that fragments global priorities (10). Our role is to advocate for true integration of prevention and care across the life course, based on shared outcomes, ensuring that mental well-being is treated as a foundational component of health, not a separate problem with a separate, and lesser, form of accountability.
Finally, there is the paradox of implementation, which often forces public health to operate on a hostile court. We invest heavily in interventions targeting individual behaviour while the powerful upstream forces shaping health are too often unchallenged, and prevention remains neglected and misunderstood. This includes the commercial determinants of health, a central battleground for NCDs but still a glaring blind spot in mental health (whilst acknowledging recent efforts by the Global Mental Health Action Network and others) (11), as well as the shared social and economic determinants such as work precarity and unaffordable housing.
Slovenia’s national experience starkly illustrates these global paradoxes. As a high-income country with a universal, predominantly public health system (12), its struggles with translating global rhetoric into national reality are emblematic of challenges faced worldwide. The country bears a significant burden from NCDs and mental health conditions, including one of the highest suicide rates in the EU (13), and has been actively working to address these issues.
The call for greater ambition, such as allocating 5% of health budgets to mental health, is immediately complicated on the ground; calculating a clear baseline is a near-impossible task when vital services are scattered across health, social and educational sectors, each with its own funding models. The need for integration is complicated by fragmented strategies; the deinstitutionalisation of long-term care, for instance, illustrates this perfectly: the strategy is led by one ministry, while the essential components for its success, from community health services to social support and participation in the labour market, remain the responsibility of others. While signs of the necessary whole-of-government coordination exist in the form of inter-ministerial working groups, the ultimate challenge remains translating this high-level dialogue into unified action on the ground. This implementation gap is illustrated by our experience with community mental health centres: while these new services are operational and successful, their ability to scale up and meet the full breadth of population needs is limited by a critical shortage of a specialised workforce.
The challenges faced in Slovenia are not unique. While the HLM declaration will offer a framework, a framework alone builds nothing. The path forward requires moving beyond the paradoxes and any laudable-but-cautious targets in the declaration, and it should be framed alongside people with lived experience - who will also step up, as ever, to hold governments to account. True success will demand greater ambition in financing, true integration measured by shared outcomes, the political courage of governments to choose public health over corporate profit by taxing health-harming industries, and to replace siloed ministry budgets with whole-of-government financing models designed around population need, not bureaucratic history.