Europeanisation and mental health reform in the Western Balkans, 2005–2025

Background

Mental health is increasingly recognised as central to health and wellbeing, yet remains a marginalised policy domain. In the Western Balkans, mental health reform has lagged behind broader health system transformation. While Europeanisation – the diffusion of EU norms and governance practices into domestic policy – has shaped reforms across sectors, its influence on mental health has not been systematically examined. This study assesses how the EU accession process has shaped mental health reform across six Western Balkan countries between 2005 and 2025.

Methods

We conducted a qualitative content analysis of 118 annual EU Progress Reports for Albania, Bosnia and Herzegovina, Kosovo, Montenegro, North Macedonia and Serbia (2005–2025). All mental health-related text segments were extracted and coded against an integrated framework combining Tresa et al.’s Europeanisation model (contextual, distal, proximal levels) with the European Observatory’s Health Systems Performance Assessment framework (governance, resource generation, financing, service delivery).

Results

Of 118 reports, 107 (91%) referenced mental health reform. Findings reveal a consistent implementation gradient. Europeanisation effects were strongest at the contextual level, where all six countries adopted mental health legislation and strategies; weaker at the distal level, where infrastructure expansion outpaced sustained financing and workforce investment; and weakest at the proximal level, where deinstitutionalisation remained partial and uneven. Institutional psychiatric care continued as the default model despite formal commitments to community-based reform.

Conclusions

Accession-driven conditionality functions as a trigger for regulatory reform but not a sustained driver of service-level transformation. Embedding implementation-focused monitoring on financing, workforce and community-based transition is essential to translate governance convergence into system change.

Key messages

• Across the Western Balkans, EU accession has driven the adoption of mental health legislation and strategies, but financing, workforce and service delivery reforms have consistently lagged behind.

• Findings demonstrate that EU accession can advance regulatory alignment in mental health policy but does not, on its own, deliver the structural reforms needed to transform service provision.