Policy ambition constrained by structural inertia: Insights from mental health reforms in Georgia.

Background

Mental health reforms have increasingly aimed to shift care away from psychiatric hospitals toward community-based, person-centered models. However, implementation has often remained incomplete. Georgia reflects this pattern: despite national strategies promoting deinstitutionalization and community-based care, service delivery remains largely hospital-based and medication-centered. This study examines how governance arrangements and institutional dynamics shape mental health system functioning in Georgia and draws lessons relevant to comparable settings.

Methods

This mixed-methods study combined a desk review of mental health policies and prior assessments, secondary analysis of financial and administrative data (2018-2024), and qualitative interviews with 41 stakeholders across five regions of Georgia. Qualitative data were thematically analyzed, and findings were triangulated across sources.

Results

Mental health system performance was shaped by weaknesses in governance, financing, service organization, workforce, and information systems. Governance was weakly operationalized, financing remained hospital-centered, and service delivery was fragmented and unevenly distributed. Workforce shortages, low remuneration, and administrative burden reinforced medication-centered care. Together with poverty, stigma, and housing insecurity, these factors sustained reliance on institutional care.

Conclusions

Meaningful reform requires stronger accountability, financing that supports community-based care, workforce rebalancing, and expanded services beyond hospital settings.