Stakeholder perspectives on the WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) in humanitarian settings: a qualitative study in Lebanon and Iraq

Background: The mental health treatment gap remains substantial in countries affected by humanitarian crises, where fragile health systems and structural instability hinder service delivery. The World Health Organization's Mental Health Gap Action Programme (mhGAP) aims to scale up evidence-based mental health care through integration into primary health care. However, its real-world implementation in humanitarian settings remains underexplored. Methods: We conducted a qualitative study using in-depth individual interviews with 12 stakeholders, including primary care practitioners, mhGAP trainers, field supervisors and health managers involved in the implementation of WHO mhGAP training over the past five years in Lebanon and Iraq. Thematic analysis was applied to explore perceptions of training effectiveness, implementation dynamics, and contextual determinants influencing the mental health service delivery at primary health care level. Results: The main findings of the study revolved around the following dimensions: (1) cases involving suicide risk and substance abuse are considered more challenging, requiring additional skills and coordination with specialized services; (2) the stigma surrounding mental health within communities and among healthcare providers further hinders access to care; (3) poor continuity of care restrict effective mental health care delivery; (4) the mhGAP training enhances knowledge and skills, but changing attitudes and clinical practices are directly influenced by local health systems and policies; (5) continuous supervision is crucial for changing clinical practices and ensuring care aligns with evidence-based guidelines; (6) effective monitoring mechanisms are needed to ensure the training meets its objectives and improves access to mental health care at the primary level. Conclusions: The mhGAP training experiences have shown potential in bridging the mental health treatment gap, while a stark disparity in access to mental health services is evident within countries, which is particularly acute for populations in humanitarian settings where instability and resource scarcity compound mental health challenges. This accentuates the urgency of targeting investments in the most underserved areas, and calling for a nuanced approach that recognizes the complex interplay of social, cultural and economic factors influencing health service delivery.