An insider-outsider’s view of the High-Level Meeting on NCDs and Mental Health

There we are, mental health had its major debut at a UN High-Level Meeting (HLM) last week. But was it a success? I worked on it for 18 months and I think it was.

Process Is Key

Whilst in the 2018 third HLM on NCDs political declaration mental health was explicitly named as a topic for the next HLM, it was far from certain that mental health would have such prominence in this fourth meeting. I would go as far as saying that it may have not been a consideration 18 months ago. 

To understand the success of mental health last week we need to remember the momentum the issue has built over the past three years at global inter-government discussions. We have seen resolutions (or similar) on mental health at the UN Security Council, UN General Assembly, World Health Assembly, and the Human Rights Council, adding to mentions of mental health in G7 and G20 summits, the Summit of the Future, and crucially at regional political gatherings.

After years of being overlooked, mental health feels like a mainstay in global health discussions, and beyond. For this momentum to translate into success at this HLM, governments, and critically their diplomats, needed to be knowledgeable of mental health technicalities, and invested in the issue. 

This education has taken a huge collective effort. As well as government HQs informing their representatives at the UN, neutral conveners such as the UN Foundation and WHO, and global and national civil society, have worked tirelessly to ensure that those working on the HLM negotiations at the UN have the correct information they need and understand the cross-cutting importance of mental health.

We at UGMH have met with over 60 governments this year alone to discuss the intricacies of mental health at this years’ HLM.

Maintaining dialogue with this number of governments was impractical, if not impossible, so we identified nodes of power – those governments negotiating on behalf of groups of governments, influential governments within their region or on specific issues, and those who have influence over the influential.

We tried to be focussed on ‘who’ and concise with the ‘what’ as diplomats are some of the most time-poor people I have met. As governments got closer to the final political declaration and things became more urgent, we sent fewer and shorter emails, we only had some many opportunities to influence, we had to use them wisely.

All of this was threatened by the drama on the day. There is no need to panic or be disheartened, the political declaration will be adopted. Think of a HLM like a parliamentary committee where bills are drafted and debated before being sent to the main chamber (in this case, the UN General Assembly) to be voted on. They have the yes votes, a lot of them in fact. However it is worth reflecting on our performance.

We say that we are living in “different times” but have we really changed our advocacy game plan?

We knew about the high probability that the political declaration would go to a vote but didn’t spot the line in the Modalities Resolution about the political declaration needing consensus, (To be honest, I was focussed on the title including mental health and the timing of the political declaration negotiations).

A more pleasant reflection is the involvement of civil society and experts by experience. I felt that the mental health community came together in a way I haven’t experienced when working on other health issues. ‘Team Mental Health’ was largely coordinated (Thanks to Global Mental Health Action Network), focussed, put the goal before self-interest, and was kind – it has been a pleasure to be on the team.

I know some disagree but I think there was good involvement of us in this HLM process – the Multi-stakeholder Hearing was a high watermark for me. Remembering that the 160 governments that spoke at the HLM last week have mostly been fairly elected to be there and many of us in civil society don’t have that mandate, I think our representation was fair and governments heard our concerns and suggestions.

My frustration is more about the tentacles of harmful companies. They have a right to share their opinions but surely there can be better safeguards in place; the GMHAN has recently produced guidance for civil society groups to protect themselves.

However, the space given to civil society is small and under threat, we both need to defend it and make the best use of what we have for those we represent.

Moreover, the language in the political declaration on systemic and meaningful social participation, including lived experience, is weak and disappointing. 

The Political Declaration

You’re only as good as your last political declaration. It is important to bear in mind that a political declaration is just that, a political document not an implementation guide, a statement of intent not a binding agreement. What we needed were clear and simple commitments and now we have six years to pressure their implementation.

For example, the commitment to deinstitutionalising mental health systems – maybe the greatest mental health reform required by nearly all countries – is just 18 words in the political declaration and that is good enough. We have the WHO guidance on deinstitutionalising mental health systems as well as regional and national plans that give the detail. ‘Good enough’ worldwide political commitments in these times are okay, even a major success in our case.

Deinstitutionalisation was one of four priorities set by the mental health community over a year ago, along with young people’s mental health, suicide prevention, and the addressing the social and commercial determinants of mental health. We took the strategic decision to reframe deinstitutionalisation as “system reform” and put the emphasis on primary and community-care integration rather than present it as a rights issue as we realised that human rights would be contested throughout the process.

Whilst I am saddened that we could not put mental health rights front and centre, I feel it was the right approach and paved the way for increased discussion about the need for an integrated mental health and NCD approach.

Young people’s mental health was more of a struggle than I anticipated. In the other global forums already mentioned, young people’s mental health has often been the access point for wider mental health, or the path of least resistance. Here, that was not the case, largely due to a small group of member states resisting any references to disaggregated populations and in doing so this meant age groups too.

The zero draft of the political declaration almost entirely left out young people; we redoubled efforts and things improved. From the outset I genuinely thought that there would be strong youth mental health language in a standalone paragraph within the political declaration but I was wrong.

The political declaration does recognise the impact of social determinants of young people’s mental health, and commits to specialised care as well a response to the unique issue of online harm, but it could have gone further with suggestions about interventions in education settings and other specifics for young people not making it into the final version. 

The suicide prevention text reads as though it has been written by mental health professionals and civil society, and is based on the WHO LIVE LIFE approach, which is excellent. 

Social and commercial determinants for mental health were the issues I felt would be hardest to work on, and so it proved. The upside is that governments acknowledge that social and commercial determinants impact mental health, when traditionally these have been viewed only through a physical health lens – we all know smoking leads to lung disease, whilst the strong link to depression is barely known.

The commitments here are weak though and we share the frustration of the physical NCD community. Whether it was having more money or better tactics, harmful industries outflanked us. 

We saw financing as a cross-cutting issue and so supported the general calls for increased and improved financing for health systems without positioning mental health finance as unique – maybe an error though in one political declaration draft mental health allocation in health budgets was mentioned with a commitment to increase, predictably this was a cameo.

The financing work began in June 2024 at the WHO and World Bank hosted Financing Dialogue, and I wonder whether that meeting could have had more impact on the HLM if it had happened in early 2025. It was always a stretch that ministries of finance would sign off sovereign tax issues (i.e. health taxes) being discussed in a health meeting in New York, but what progress that would have been.

Maybe we should take health taxes to global finance forums though I can’t see a more effective way than improving the situation country-by-country. The positive in the political declaration is the commitment to reducing out-of-pocket spending through financial protection policies – a priority before the next HLM is for mental health services to be included in public health insurance schemes as part of domestic resource mobilisation for mental health, we are seeing limited progress there.  

Much has been discussed about the targets in the political declaration with many saying they are weak. I don’t agree, in fact I find them ambitious. The health system strengthening, legislative, and financial targets would all be extremely good for mental health systems if met, and 150 million more with access to mental health services (which reminds me of the World Bank 1.5 billion target) gives us a clear number to monitor. The difficulty is the lack of specify and assigned responsibility.

So What?

Please excuse the cliche but this is just the start. These types of global agreements do not dictate national government policy, and in the era of localism and decolonialism, why should they? That does not mean they are not highly important. These agreements show governments what is expected of them and this has been done in front of their peers. It is our job as civil society to spread the news, remind governments of their word at every opportunity, as well as help them find solutions.

I do not honestly believe that governments don’t want better mental health support for their citizens; I believe they don’t currently have the resources and, despite the kind words, mental health consistently loses out in trade-offs. We need to be smart in our advocacy – push when needed, otherwise be supportive – and those of us working at the global level must give space and support to experts by experience and those working in the countries we like to cite, not just criticise others who don’t. 

For me, the success of this HLM was Team Mental Health being led by new, often unheard voices, sticking to the strategy, and achieving what it set out for.

Mental health advocates know what we need to do now but the question is, who will support us to turn words in New York into the world we want to see?