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Peru's recent national mental health (MH) reforms aim to decentralise care and expand access to MH services for rural populations by integrating services into primary healthcare through the expansion of Community Mental Health Centres (CMHCs). Evidence on the implementation of these reforms at the local level remains limited. This qualitative study aimed to (i) describe the structure and implementation framework of MH services, (ii) analyse local understandings of MH; and (iii) examine pathways to care and identify barriers and facilitators to MH service implementation from both the supply (service providers) and demand (users and community members) perspectives. MH services were mapped across three provinces of northern Peru using a review of national MH policies, 2 focus group discussions, and 31 semi-structured interviews. Data were analysed thematically to explore local understandings of MH, pathways to care, and health system barriers. Local understandings of MH are shaped by cultural beliefs, social norms, and economic conditions, with many individuals experiencing distress initially relying on family networks or traditional healers. Stigma and expectations of a quick recovery hinder engagement with formal services. While the expansion of CMHCs has improved geographical access to specialised care in rural areas through proximity and being patient-centred, the implementation of respectful provider interactions remains uneven. Weak referral pathways and limited coordination between primary care centres and CMHCs frequently shift the responsibility for navigating care onto users and their families. Family involvement and culturally sensitive practices foster trust and support continued engagement. Persistent challenges include the limited capacity of service providers, high staff turnover, and the follow-up mechanisms, stigma, and tensions between cultural and biomedical understandings of MH. Peru's expansion of CMHCs represents a significant health system reform to improve equitable access for rural populations. To sustain these gains, it will be necessary to strengthen workforce stability, clarify referral processes, and integrate culturally responsive approaches within primary care systems, offering lessons for similar resource-constrained contexts.