Tackling Neglect and Mental Health Reform in a Devolved System of Welfare Governance

A system of devolved welfare governance, it is argued, increases participation in welfare services. However, limited empirical evidence has been reported on how it influences welfare reform. This paper draws upon evidence from the mental health system in Spain, where health care is devolved to the regional states (autonomous communities), to examine whether policy reform of neglected policy areas may be triggered through heightened policy awareness and better participation of interested stakeholders. We find that regional devolution has helped to scale up mental health in some of Spain's autonomous regions relative to support for other services. Evidence suggests that whilst fragmentation and certain historical legacies remain path dependent, regional devolution has indeed enhanced experimentation, reform and policy innovation in mental health care. However, the expansion of mental health care coverage has been constrained by the lack of a clear definition of public coverage, as well as the need to meet the demands of evidence-based policy in an era of cost-containment. Inequalities in access to mental health care remain; they are compounded by the stigma and discrimination experienced by people with mental health problems, which is a common challenge for all health systems in Europe.