Local Excellence and National Strategy: Bridging the Gap

A change management process for mental health care, as described for low-income countries in the insightful Open Forum article by Belkin and colleagues, is also of importance for the European region. Many countries can showcase excellent community-based centers with high-quality staff who are trained by experts from abroad and highly committed. The centers have in common inspirational leadership by an influential change agent, often a psychiatrist, who has made tremendous efforts to establish the mental health service, persuading local leaders and international agencies to fund these so often stigmatized services.

Many of these countries also have good mental health strategies, proposing comprehensive models of community-based mental health services, but they are struggling to implement them. Such strategies require major changes in service structures and ways of working, additional investments in services, staff numbers, and training, and the commitment of many agencies. Important lessons could be learned from model services that are already functioning in exemplary fashion.

So, why are the lessons often ignored? Why is there a gap between excellent local practice and national implementation? In strategy meetings where national leaders of psychiatry plan dissemination-of-care models, these local services are sometimes not even mentioned, even though their aims and outcomes are identical to strategic priorities. It may be that these services are not accepted as mainstream but are seen as exceptional. From a national perspective, required to focus on the balance between the mental health needs of the population and the resources made available in the budget, these local services appear not to be replicable because they rely on external funding and exceptional staffing levels.

The pity is that by rejecting these services as national models, valuable expertise is lost that could steer progress, such as how to organize local services, train staff, and engage patients and families. The essential achievements of these centers—the shifting of services from institutions to the community—are overlooked. Local success can be transferred into national practice by simplifying care models without losing their therapeutic essence. Openness to adapt to local circumstances is at the core of effective dissemination.

Transforming local model services into national programs offers opportunities to build on experience. Failure to recognize these opportunities impedes national implementation and works against the goals of both governments and donors. The process described by Belkin and colleagues can help us promote effective services.

Editor's Note: This commentary is the author's personal opinion and does not necessarily reflect official WHO policy.