A Case for Shifting Mental Health Care from Institutions to Communities

Anura Kumara Dissanayake and Tedros Adhanom Ghebreyesus write that institutionalized mental health care is “obsolete” and “a human rights issue in plain sight.”

In recent decades, many countries have made significant progress in developing community-based mental health services. In addition, rights-based approaches have gained attention as people with lived experience increasingly have a say in shaping mental health policy and services. These developments have shown that people living with mental health conditions can thrive in their communities if given the right support.

However, around the world, far too many people with mental illness live behind closed doors in psychiatric hospitals and social care institutions. Some have been there for months. Others have been brought home against their will, denied basic daily choices like dressing or eating, and cut off from the outside world for decades, according to the World Health Organization's Mental Health Atlas.

We think of institutional mental health care as an outdated model. But it is much more than that. This is a human rights issue hidden in plain sight. Many countries still rely heavily on independent psychiatric institutions. Worldwide, we estimate that nearly half of public mental health funding goes to maintaining these large facilities, while access to community-based mental health care, including in public hospitals, is underfunded and neglected for millions of people.

Sri Lanka embraced mental health care reforms by replacing isolated institutions with community-based services. Leading the country's mental health over the past 20 years, Sri Lanka has made significant progress in transforming the mental health system from a refuge-based model to a decentralized network of regional and community services. Today, mental health care in Sri Lanka is provided through inpatient and outpatient units in general hospitals, auxiliary clinics, intermediate rehabilitation units and child mental health clinics throughout the country.

Facilities that support human rights, dignity and personal autonomy promote recovery. However, when care is characterized by coercion, strict control or social isolation, it risks becoming a form of imprisonment rather than care.

Deorganization is not just about reducing hospital beds. It is about creating the conditions for independent living and full participation of people in society with access to appropriate housing, education, employment, social support and person-centred mental and physical health care. It is the foundation of human rights-based mental health improvement, inclusion and care.

Reducing psychiatric hospital beds must be accompanied by the creation of local services and practical supports – housing, community mental health care, peer support, social contact, education and employment, legal support, and family support. No one should be discharged without ongoing care. People should be welcomed into the services and communities that are ready for them.

Countries around the world are making progress. Deorganization is achievable at all income levels, from changing care practices and expanding alternatives to psychiatric hospitals to creating comprehensive networks of community-based services. Deorganization is a cultural change that requires the meaningful participation of people with lived experience, health care providers, and the community as a whole.

To support this transition, WHO has published new practical guidelines to help health leaders navigate each step. Each country starts from a different position with different resources, laws, service systems and social networks. Implementers need to identify practical and impactful actions that are appropriate for their context.

We must ensure that people receive the support they need in environments that promote dignity, independence, relationships and inclusion. We call on governments, health and social care systems to make this a priority and to have people with lived experience as partners throughout the transition.