Matej VINKO 1* , Téa COLLINS 2 , Antonis KOUSOULIS 3 A PATH TO TRUE INTEGRATION: MAKING GLOBAL MENTAL HEALTH COMMITMENTS A NATIONAL REALITY 1 National Institute of Public Health, Trubarjeva cesta 2, 1000 Ljubljana, Slovenia 2 World Health Organization, Geneva, Switzerland 3 United for Global Mental Health, London, UK & Global Mental Health Action Network, London, UK Received: Sep 12, 2025 Accepted: Oct 14, 2025 Invited editorial *Correspondence: matej.vinko@nijz.si 10.2478/sjph-2025-0023 Zdr Varst. 2025;64(4):178-180 178 POT DO UČINKOVITE INTEGRACIJE: OD GLOBALNIH ZAVEZ ZA DUŠEVNO ZDRAVJE DO NACIONALNE REALNOSTI © National Institute of Public Health, Slovenia. Vinko M, Collins T, Kousoulis A. A path to true integration: Making global mental health commitments a national reality. Zdr Varst. 2025;64(4):178-180. doi: 10.2478/sjph-2025-0023. ABSTRACT Keywords Mental health Noncommunicable diseases Global health governance Integration Implementation IZVLEČEK Ključne besede duševno zdravje nenalezljive bolezni globalno upravljanje zdravja integracija implementacija The forthcoming United Nations General Assembly High-Level Meeting on noncommunicable diseases and mental health offers a crucial opportunity to advance global health governance. This editorial argues that while the draft declaration represents a vital step forward, its potential to address global mental health needs is complicated by several paradoxes that merit careful consideration. First, its targets for financing and access may not fully reflect the ambition needed to overcome systemic underinvestment. Second, the “integration paradox” champions a cohesive approach while setting different types of targets for mental health and NCDs. Finally, an implementation paradox is evident in the ongoing focus on individual behavior rather than on the upstream social and commercial determinants of health. Using Slovenia’s experience as a national case study, we illustrate how these global challenges can complicate efforts to translate high-level commitments into national reality. We conclude that for the UN Political Declaration to be truly transformative, it must inspire a shift from cautious frameworks to more ambitious financing, authentic integration, and the political courage to prioritise population needs over siloed institutional legacies. Prihajajoče zasedanje Združenih narodov na visoki ravni o nenalezljivih boleznih in duševnem zdravju ponuja ključno priložnost za napredek v globalnem zdravstvenem upravljanju. V tem uvodniku opozarjamo, da ima politična deklaracija sicer velik potencial za izboljšanje področja duševnega zdravja, vendar pa ga omejujejo trije ključni izzivi. Prvič, cilji za financiranje in dostopnost storitev morda ne odražajo ambicij, ki so potrebne za premagovanje sistemskega podinvestiranja na področju duševnega zdravja. Drugič, »paradoks integracije« zagovarja oblikovanje celostnih storitev, a obenem vzpostavlja različne sklope kazalnikov za duševno zdravje in nenalezljive bolezni. Nazadnje, »implementacijski paradoks« je očiten v vztrajnem poudarjanju spreminjanja vedenja posameznika, namesto vplivanja na širše družbene in komercialne determinante zdravja. Na podlagi izkušenj iz Slovenije prikazujemo, kako lahko tovrstni paradoksi otežijo prenos zavez na visoki ravni v nacionalno realnost. Da bi bila deklaracija ZN resnično prelomna, mora spodbuditi premik od previdnih pristopov k ambicioznejšemu financiranju, učinkoviti integraciji in političnemu pogumu, da se opustijo ukoreninjeni institucionalni procesi v korist potreb prebivalstva. 1 INTRODUCTION 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). 2 THREE PARADOXES The public health community must first dissect and confront three central paradoxes embedded within the 10.2478/sjph-2025-0023 Zdr Varst. 2025;64(4):178-180 179 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. 3 FROM GLOBAL RHETORIC TO NATIONAL REALITY 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. 10.2478/sjph-2025-0023 Zdr Varst. 2025;64(4):178-180 180 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. CONFLICTS OF INTEREST The author declares no conflicts of interest. FUNDING This article was completed without external funding. ETHICAL APPROVAL Ethical approval for this article is not needed. AVAILABILITY OF DATA AND MATERIALS Not applicable. DISCLAIMER The views expressed in this publication are solely those of the authors and do not necessarily reflect the views, policies, or decisions of the organisations with which they are affiliated. ORCID Matej Vinko: https://orcid.org/0000-0003-0396-4510 Téa Collins: https://orcid.org/0000-0002-7406-829X Antonis Kousoulis: https://orcid.org/0000-0002-8763-3358 REFERENCES 1. Wahlbeck K. Public mental health: The time is ripe for translation of evidence into practice. World Psychiatry. 2015;14(1):36-42. doi: 10.1002/ wps.20178 2. GBD 2019 Mental Disorders Collaborators. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990– 2019: A systematic analysis for the Global Burden of Disease Study 2019. Lancet Psychiatry. 2022 Feb 1;9(2):137-50. doi: 10.1016/S2215- 0366(21)00395-3 3. Kousoulis A, Van Bortel T, Hernandez P, John A. The long term mental health impact of COVID-19 must not be ignored. BMJ Opinion. 2020 May. 4. Campion J, Javed A, Lund C, Sartorius N, Saxena S, Marmot M, et al. Public mental health: Required actions to address implementation failure in the context of COVID-19. Lancet Psychiatry. 2022 Feb 1;9(2):169-82. doi: 10.1016/S2215-0366(21)00199-1 5. Akselrod S, Collins TE, Berlina D, Collins A, Allen LN. The impact of UN high-level meetings on non-communicable disease funding and policy implementation. BMJ Glob Health. 2023 Oct;8(10):e012186. doi: 10.1136/ bmjgh-2023-012186 6. McGorry PD, Mei C, Dalal N, Alvarez-Jimenez M, Blakemore SJ, Browne V, et al. The Lancet Psychiatry Commission on youth mental health. Lancet Psychiatry. 2024 Sep 1;11(9):731-74. doi: 10.1016/S2215-0366(24)00163-9 7. 7.Patel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolton P, et al. The Lancet Commission on global mental health and sustainable development. Lancet. 2018 Oct 27;392(10157):1553-98. doi: 10.1016/ S0140-6736(18)31612-X 8. United for Global Mental Health. Financing of mental health: The current situation and ways forward [Internet]. 2023 [cited 2025 Sep 3]. Available from: https://unitedgmh.org/app/uploads/2023/10/Financing- of-mental-health-V2.pdf 9. OECD. Measuring population mental health [Internet]. 2023 [cited YYYY Mon DD]. Available from: https://www.oecd.org/en/publications/ measuring-population-mental-health_5171eef8-en.html 10. Zaletel Kragelj L, Eržen I. Does the era of globalization dictate a change in the definition of public health? Zdrav Varst. 2024 Mar 20;63(2):63-5. doi: 10.2478/sjph-2024-0009 11. Dun-Campbell K, Hartwell G, Maani N, Tompson A, van Schalkwyk MC, Petticrew M. Commercial determinants of mental ill health: An umbrella review. PLoS Glob Public Health. 2024 Aug 28;4(8):e0003605. doi: 10.1371/journal.pgph.0003605 12. Polin K, Poldrugovac M, Albreht T. Slovenia: Health system summary, 2024. Copenhagen: European Observatory on Health Systems and Policies; 2024. 13. OECD, European Observatory on Health Systems and Policies. Slovenia: Country health profile 2023 [Internet]. 2023 [cited 2025 Sep 3]. Available from: https://www.oecd.org/en/publications/slovenia-country-health- profile-2023_0eb17a30-en.html