The socio-political context shaping CAMH responses

Context refers to the socio-political conditions that shape whether CAMH becomes visible as a public problem and whether political attention can be translated into sustained action. Across the four countries, CAMH trajectories were consistently shaped by the interaction of regime type and State capacity, conflict dynamics and humanitarian governance, and socio-cultural norms shaping the legitimacy of mental health.

Regime type and State capacity shaped the governance arrangements through which CAMH could be pursued. Where governments had authority and capacity, whether through legal mandates or technocratic stewardship, CAMH could be embedded within State-linked institutions as an early move towards institutionalization, even if implementation was initially uneven. Where State capacity was constrained, CAMH commitments often remained symbolic or project-based, and humanitarian logics predominantly shaped programme design and sustainability pathways. These differences determined whether CAMH entered political agendas, what forms of MHPSS were politically acceptable, and crucially, whether commitments could survive beyond individual crises.

Conflict dynamics and humanitarian governance shaped who could deliver CAMH services and on what terms. Security conditions, humanitarian access routes and local power dynamics determined whether services could reach children, producing uneven “geographies of care” in which State and non-State forces functioned as de facto veto players. Under these conditions, national policies often remained contested, and effective authority clustered around actors able to operate within multi-actor fragmented ecosystems, irrespective of formal mandates.Footnote ⁴¹

Conflict-related distress and acute shocks heightened visibility of children’s psychological suffering in all four contexts, signalled legitimacy for this issue, strengthened the case to intervene, and unlocked financial and human resources. At the same time, these conflict-related dynamics also prioritized actors and agendas that came with resources, political power, and implementation capacity, often reshaping the CAMH ecosystem in some contexts. Within this fragmented landscape, humanitarian funding structures often emphasized rapid scale and visible reach. This expanded delivery of MHPSS interventions across community-based platforms, schools and learning centers, and health facilities to varying extents. At the same time, these humanitarian logics often risked core system strengthening functions including supervision, referral pathways, workforce retention, and specialist service delivery systems remaining under-resourced. Humanitarian governance thus became a central organizing force across all four countries, particularly during acute crises. While this enabled rapid expansion of MHPSS where State systems were absent or overwhelmed, it also introduced structural constraints rooted in the political economy of humanitarianism. Humanitarian funding structures in these conflict contexts often emphasized rapid scale and visible reach. This expanded delivery of MHPSS interventions, especially across community-based platforms, schools and learning centres, and health facilities to varying extents. At the same time, these humanitarian logics often risked core system strengthening functions such as supervision, referral pathways, workforce retention and specialist service delivery systems remaining under-resourced.

Crucially, informants consistently described how this competitive marketplace generated a secondary mechanism of institutional erosion: an internal talent drain. The influx of international funding created a dual labour market in which INGOs and UN agencies could offer salaries significantly higher than public institutions, which one interviewee characterized as effectively “cannibalizing” the State’s human resources. In Lebanon, an informant described losing staff from State entities to INGOs that offered better salaries and incentives, whereas in Syria, an INGO informant noted: “If salaries were better, services and quality would improve, and staff would stay. We train people, invest in them, and then they leave for slightly better pay elsewhere. … This is a major and fundamental issue.” In Haiti, the same dynamic played out through project cycles rather than salary competition alone, with one informant saying: “We end up recruiting people, training them, and then they leave when the project ends, and then we recruit new people and train them again.” Several informants described how this constant turnover made it very hard to build lasting capacity. Across contexts, these arrangements generated durable path dependencies, stripping national institutions of their most capable staff precisely when they were most needed, and producing cycles of recruitment, training and attrition that eroded institutional memory over time. While humanitarian substitution prevented system collapse and expanded access, informants emphasized that it had also entrenched what one informant described as a “shadow State” of donor-driven priorities, alongside a fragmented authority structure and a crowded landscape of MHPSS tools and frameworks. Informants often described these dynamics as complicating efforts to consolidate institutions as conflicts evolved or shifted toward transition.

This intersection of regime type, State capacity, conflict dynamics and humanitarian governance produced distinct but patterned trajectories. In Colombia, relatively strong legal authority allowed CAMH to be anchored through enforceable mandates, while humanitarian engagement functioned to complement, support and translate policy attention into operational tools, guidance and services at the national level, and to provide operational scaffolding where the State could not reach, especially in conflict-affected peripheries. In Syria, historically, centralized authority combined with protracted conflict created a distinct humanitarian–State governance ecosystem in which CAMH emerged at the intersection of State oversight and humanitarian operations. Following the change in government in 2024, several informants noted that this ecosystem seems to be evolving, though much remains to be seen. In Haiti, fragile governing capacity and chronic insecurity created a hard ceiling for CAMH, with external actors often performing core governance functions alongside, or mostly in parallel with, the State. Lebanon followed a hybrid trajectory in which humanitarian expansion, especially initially, concentrated resources and agenda-setting power among international actors; however, a confluence of factors, as discussed below, enabled the development of a technocratic coordination anchor within the State that partially mitigated fragmentation without fully displacing humanitarian- and donor-driven priorities and dynamics.

Socio-cultural norms, including idioms of distress, relational expectations and socially recognizable frames, further shaped the legitimacy of CAMH responses. These functioned as informal rules that structured help-seeking pathways, professional authority (i.e., who is seen as a legitimate helper) and the social risks attached to naming mental health as a policy problem, thereby shaping what kinds of CAMH interventions could be publicly endorsed and normalized.

Across contexts, distress was commonly interpreted through spiritual, relational or somatic idioms, while psychiatric labelling carried significant social risk. This often meant that health and community workers trained in biomedical or psychological frameworks encountered families who did not recognize, or did not use, the same categories. Addressing this dissonance – for instance, by aligning mental health with socially recognizable, and sometimes politically neutral, frames – enabled access. Where it was left unaddressed, it shaped not just whether families sought care, but also through which platforms and from whom.

Moreover, these norms were not fixed cultural traits; they were continually reshaped by conflict, political violence and social fragmentation. Crisis conditions widened social acknowledgement of MHPSS needs without eliminating stigma, normalizing distress, as informants noted, as a “normal reaction to abnormal situations”. The visibility of psychosomatic symptoms such as bedwetting, headaches and gastrointestinal symptoms, as well as reported cases of suicide-related deaths or attempts, was identified across contexts as particularly influential in breaking the culture of silence around mental health. Children’s suffering carried strong moral legitimacy, while adolescents’ distress, particularly among boys, was more often framed through lenses of risk or deviance, narrowing sympathy and political support.

Finally, norms shaped professional authority in ways that intersected with task-sharing arrangements. In some contexts, traditional healers, religious figures or teachers held de facto authority that formal CAMH systems needed to navigate and complement, rather than replace. Where standardized psychological or psychiatric models failed to accommodate these plural understandings of well-being, uptake was constrained both by the structural barriers to accessing MHPSS and by the perceived legitimacy (or lack thereof) of the intervention itself.

Agenda-setting and how CAMH entered the political discourse

Agenda-setting refers to the processes through which CAMH gained visibility, legitimacy and priority within political discourse. Across contexts, CAMH did not enter political agendas through linear diffusion of global norms or evidence alone. Instead, agenda entry emerged through contested, context-specific processes at the intersection of crises, problem framing, institutional incentives and actor capacity. Crucially, the same dynamics that elevated CAMH onto political agendas often constrained the forms of action that followed.

Crises and shocks, including armed conflict, displacement, disasters, epidemics and political transitions, heightened the visibility of children’s distress and lowered resistance to acknowledging mental health as a public concern. At the same time, these crises typically opened short-lived policy and governance windows whose effects depended on how they were leveraged. Across all four contexts, the presence or absence of policy entrepreneurs and technically skilled institutional actors emerged as a consistent determinant of whether and how CAMH gained political traction. When such actors were present and well positioned, they translated crisis visibility into concrete proposals that governments could own and act on, and crises were more likely to function as ladders, enabling CAMH to enter political discourse and institutional spaces. When their capacity was limited, fragmented or absent, and/or their enabling environment more constrained (whether in terms of political will or access to resources and tangible solutions), crises functioned as ceilings, compressing time horizons and subordinating mental health to immediate survival, security or fiscal pressures.

The country cases illustrate both dynamics. In Lebanon, successive shocks shifted mental health from a private matter to a shared social reality, and when the Syrian refugee crisis exposed serious coordination failures in the system, skilled actors moved quickly to establish the NMHP and build coordination platforms around it. In Haiti, the 2010 earthquake broke through long-standing political neglect and triggered significant humanitarian mobilization, yet subsequent cycles of insecurity and political paralysis repeatedly narrowed the pathway forward, converting visibility into episodic attention that rose and fell with each new crisis without ever consolidating into sustained systems investment. Similar patterns appeared in Colombia and Syria, where recurring crises opened windows for CAMH but institutionalization remained partial.

Thus, norm promotion and issue construction played a key role in shaping how CAMH entered national agendas amidst crises. Norm promotion refers to the processes through which global and regional frameworks shape how issues are defined, governed and acted upon at the national level, and issue construction refers to the socio-political processes through which a problem is made legible, governable and actionable within a specific context.Footnote ⁴² Across contexts, MHPSS norms did not “land” as ideas alone. They took effect through the aid delivery machinery, which formatted how MHPSS was designed, funded, implemented and evaluated, producing systematic distortions in practice. Global and regional frameworks were selectively mobilized, adapted or muted to fit political incentives, sectoral boundaries, and sensitivities around authority, stigma and structure. These dynamics generated broad recognition that CAMH required attention, even when they did not resolve tensions around how the issue should be defined or governed.

Some informants pointed to how global frameworks and tools like the Inter-Agency Standing Committee’s (IASC) 2007 Guidelines on Mental Health and Psychosocial Support in Emergency Settings functioned as a reference point that shaped how CAMH was framed, coordinated and resourced at the national level.Footnote ⁴³ However, rather than reconciling ideological divides between biomedical and community-based approaches, the guidelines “managed” them through the composite category of MHPSS alongside a tiered intervention pyramid, enabling a degree of unification and coordination without requiring agreement on a single model of distress or care. As these norms spread across countries into national policy and practice, they carried forward unresolved tensions over what constituted legitimate intervention and who was authorized to lead. They also reshaped who had influence over how CAMH was defined, tending to privilege specific types of interventions and indicators over others, sometimes co-existing and other times contesting with locally embedded explanations and everyday practices, though unevenly. In doing so, they shaped not only coordination but also the ways in which CAMH was understood and enacted in policy and programming.

Over the past decade, particularly since COVID-19, global leadership and ministerial forums elevated CAMH into executive and interministerial spaces, strengthening the legitimacy of multisectoral policy action.Footnote ⁴⁴ Mental health evolved as a policy concern at the intersection of multiple converging pressures, including mid- and post-pandemic disruption and public anxiety, rising concern about youth self-harm and learning loss, escalating displacement and protracted crises, and a wider governance turn toward “human capital”, productivity and social cohesion narratives that made mental health a cross-sector investment claim rather than a niche clinical agenda. At the same time, the very features that made CAMH easier to elevate, such as its moral salience and the visibility of mental health distress among children and adolescents, also made it vulnerable to a narrowing of problem definition. Distress became easier to name, fund and act upon as an individualized “mental health” issue than to confront through its socio-structural determinants (violence, insecurity, poverty, exclusion, school collapse, constrained rights and protection). In practice, this often privileged interventions that were administratively tractable and could restore short-term functioning, while leaving upstream determinants less confronted and resourced.

National actors drew on these transnational norms in distinct ways. In Colombia, civil society coalitions, victims’ organizations, professional bodies and youth movements advanced CAMH through a rights- and reparations-based framing linked to the peace process, recasting children’s distress as a matter of justice and State obligation. Regional norm processes like the Declaration of Caracas were often noted as influential in shaping these shifts. In Lebanon, norm promotion relied more on epistemic authority and mainstreaming, with policy entrepreneurs playing a key role in translating transnational and domestic norms to mainstream mental health as a multisectoral priority. In Syria, action was enabled by two parallel dynamics. First, external advocacy and humanitarian documentation of refugee mental health needs, and second, a cautious domestic framing of CAMH as politically neutral psychosocial or medical care delivered through clinics, schools and communities. Following the post-2024 transition, CAMH has increasingly been reframed by emerging authorities and international actors as relevant to State legitimacy, reintegration and social cohesion. In Haiti, CAMH was more often constructed through child protection and security logics amid weak State systems and limited data infrastructure. This framing enabled episodic programming during crises but sometimes constrained broader institutionalization.

Across contexts, these framing strategies expanded coalitions but foregrounded persistent tensions. Despite IASC guidance, informants described enduring divides between “mental health” and “psychosocial support” which manifested not only as conceptual disagreement but as struggles over jurisdiction, budgets and professional authority. Mental health was repeatedly framed as cross-cutting, increasing visibility but diluting custodianship and accountabilities; for instance, while having political brokers and institutional anchors such as the NMHP in Lebanon partially mediated this fragmentation, parallel coordination platforms continued to generate ambiguity over authority and coherence.

Across cases, evidence functioned as a strategic resource for agenda-setting and institutionalization. Epidemiological data, needs assessments and service-use results were selectively deployed to frame CAMH as a critical problem that was difficult to dismiss, and to justify particular forms of intervention, even when disagreements persisted over scope or custodianship. In Lebanon, practitioners noted that they used empirical data from the national suicide lifeline to prove that youth needed dedicated services. Similarly, the 2024 Global School Health Survey (GSHS) revealed “very alarming” trends in suicide ideation, anxiety and substance use among adolescents (ages 12–17) in Lebanon, and technical specialists and policy entrepreneurs explicitly leveraged this data, with one government official stating: “The results of this GSHS are yet another trigger for us to really work on devising a plan or policy, maybe a roadmap to really consider the adolescent’s mental health.” Similar themes emerged from Colombia, where national situational analyses on suicidal behaviours were used to amplify attention on youth mental health, and in Syria, where evidence generation tied to national scalable CAMH programmes helped generate significant data that technical specialists could use for programme and policy advocacy.

Viable programme and policy solutions thus played a critical role in making CAMH a tractable policy concern that governments, often alongside non-State actors, could address. Manuals, protocols and intervention packages made CAMH governable by translating diffuse CAMH needs into concrete activities that could be funded, endorsed, planned, staffed, monitored and audited. Informants across contexts emphasized that efforts to standardize manuals often emerged as a corrective reaction to duplicative or divergent tools, definitions and practices with limited oversight and quality consistency. In each context, these efforts produced, albeit to varying extents, shared models and service platforms that governments could endorse, resource and sustain beyond individual projects.

Piloting and evidence generation further reduced political and administrative uncertainty by signalling feasibility. Across most contexts, pilot interventions demonstrated that CAMH could be delivered through existing platforms without creating new institutional structures, or in administratively and politically aligned ways, reducing the perceived costs and risks of government endorsement. In Colombia, global tools such as Helping Adolescents Thrive, EASE, and I Support My Friends were repeatedly described as “ready-made” options that could be integrated across health, education and protection systems. In Lebanon, feasibility was demonstrated through diverse pilots led by universities, NGOs and UN agencies, often in collaboration with the NMHP and relevant ministries, which reduced costs and bypassed stigma associated with CAMH. The suicide prevention helpline launched by Embrace functioned similarly. Comparable arrangements were observed in Haiti, where the Haitian Psychological Association operated a donor-supported emergency hotline. Task-sharing and stepped-care models such as mhGAP, PM+, and community- and school-based counsellor cadres trained via standardized manuals and models reinforced this dynamic by positioning non-specialist cadres as legitimate implementers under conditions of specialist scarcity.

Finally, political risk was often actively absorbed by non-State actors, further enabling prioritization. Across contexts, UN agencies, professional bodies and NGOs supplied technical expertise, staffing capacity and policy development support that lowered the transaction costs of action for governments. In Colombia, the Colegio Colombiano de Psicólogos worked closely with legislators to translate political intent into draft legal language, standards and implementation pathways. In Lebanon, UNICEF financed and staffed the development of a CAMH sub-strategy with WHO and the NMHP, temporarily substituting for constrained State capacity. Additionally, the NMHP, WHO and partners developed costing analyses and investment cases for MHPSS, establishing the “economic rationale for investing in mental health”.Footnote ⁴⁵

Critically, this required the presence of cohesive policy communities and skilled policy brokers. Policy entrepreneurs operating across institutional boundaries or technically skilled officials embedded within State structures such as national mental health programmes, ministries, or interministerial bodies play a distinct but complementary role, actively coupling problems, solutions and political opportunities as windows open. Cohesive, well-coordinated policy communities sustained problem definition, preserved institutional memory and developed viable policy solutions amidst political fragility, especially in Lebanon and Colombia. When fragmented or externally mediated, CAMH remained episodic, project-bound and vulnerable to turnover and donor cycles. These communities were not monolithic, and long-standing conceptual and professional tensions, particularly between clinical mental health and PSS paradigms, persisted across all cases. As noted earlier, these tensions are not simply semantic disagreements but operational and political struggles over who leads, implements, governs and advances what type of CAMH interventions. Where actors negotiated a minimal set of shared rules (such as definitions, referral thresholds or an agreed first-line package), coordination improved despite the lack of total consensus. However, this required sustained political work to broker authority, clarify roles and coordinate efforts, rather than epistemic agreement on models of distress or care. Notably, several informants distinguished between a broader CAMH ecosystem and a smaller technical core holding disproportionate agenda-setting and convening power, especially in Syria, Lebanon and Colombia. These actors functioned as policy entrepreneurs, coupling problems, solutions and political opportunities as windows opened, often drawing influence less from formal authority than from technical legitimacy, relational capital and access to resources.

By contrast, in Haiti, informants reflected a comparatively thin policy community. Although State institutions, UN agencies, INGOs and civil society engaged on CAMH-related issues, they rarely operated within a cohesive, well-defined policy community. High turnover, insecurity, and project-based financing undermined coalition-building and institutional memory, narrowing policy entrepreneurship to operational, sector-specific work.

Factors shaping implementation and institutionalization of CAMH beyond humanitarian response

Across the four countries, institutionalization thus depended on whether emerging policy attention could be translated into authority, financing and workforce capacity over time. Where these elements remained fragmented or substituted, implementation tended to be episodic, partial and fragile, even when policies, guidelines and technical tools existed.

Institutional authority and custodianship emerged as a key determinant of whether CAMH could function as a routine public responsibility rather than a humanitarian project. This refers to whether a State entity could claim and actively exercise ownership over CAMH by convening actors, setting standards and maintaining coherence across political transitions. This anchoring did not require comprehensive legislation or stable public financing to matter. Where authority could be asserted, whether through legal mandates, administrative circulars or technocratic stewardship, CAMH governance remained legible even when implementation was uneven. Where custodianship was absent, symbolic or substituted, CAMH initiatives were more likely to be reset by insecurity, leadership turnover and donor cycles. In Lebanon, technocratic stewardship provided a centre of gravity that convened actors, set standards and preserved institutional memory under conditions of fiscal collapse. In Colombia, authority was legally anchored but institutionally dispersed across sectors and levels of government, leaving implementation contingent on subnational capacity and political will and vulnerable to turnover. In Syria, authority has remained dispersed across ministries and is exercised primarily through administrative approval and oversight of humanitarian activity rather than through unified financing or delivery systems. Following the 2023 earthquake and the 2024 political transition, informants described early efforts to reassert institutional and interministerial leadership and review mandates, although custodianship is still being formed. In Haiti, formal mandates have existed across entities but effective national custodianship has so far been operationally lacking, with core governance functions often assumed by humanitarian actors working alongside or in parallel with State actors.

Financing arrangements and donor political economy shaped institutionalization by determining how resources reached CAMH, who controlled priorities and time horizons, and on what terms actors could operate. Across all four contexts, donor funding was indispensable in enabling CAMH to exist at scale, financing the development and implementation of manuals, pilots, projects and workforce capacity that States could not otherwise invest in. In Haiti and much of Syria, informants often emphasized that without humanitarian funding, CAMH services may “not have existed”. In Lebanon, donor financing sustained the NMHP itself, although the technical legitimacy and leadership of the NMHP mediated donor-driven priorities to some extent. At the same time, across contexts, the modalities through which financing flowed structured incentives and time horizons in ways that tested sustainability. Project-based funding favoured interventions that were fast to deploy, scalable and easily reported, while supervision, referral continuity, complex case management and workforce retention were treated as overhead. Informants across contexts described recurrent start-stop dynamics that disrupted services and eroded institutional memory, even where technical stewardship was relatively strong.

External financing, spanning humanitarian aid, development assistance and refugee-targeted funding streams from bilateral and multilateral donors, also functioned as a mechanism of governance, shaping who could act and on what terms. Under conditions of fiscal collapse, notably in Syria, Lebanon and Haiti, external funding operated as a pull factor for State engagement. Donor-defined activities and priorities often generated parallel systems of care, producing fragmented coverage and inequities. In Lebanon, refugee-targeted financing, especially in the wake of the Syrian refugee influx, created visible disparities and political tension among host communities, while higher NGO and INGO salaries accelerated the movement of skilled professionals out of public services. In Haiti, the absence of an operational public budget meant that donors directly financed and delivered services through NGOs, reinforcing repeated cycles of recruitment, training and attrition that prevented durable capacity strengthening.

Colombia represented a partial exception. National legislation and CONPES instruments have increasingly created formal budgetary hooks for CAMH within public planning frameworks, making donor financing complementary rather than substitutive at the centre. However, decentralization and uneven territorial capacity have meant that in peripheral and conflict-affected regions, donor funding continues to complement or substitute for State provision.

Workforce and implementation capacity ultimately set the ceiling on institutionalization across all four countries, but again in context-specific ways. Specialists in child and adolescent mental health were extremely scarce and were concentrated in the capital cities of Beirut, Damascus, Bogotá and Port-au-Prince, leaving rural, peripheral and conflict-affected areas largely excluded. What distinguished these four contexts from each other was the degree to which conflict and humanitarian governance dynamics actively deepened and reproduced that scarcity through specific mechanisms.

First, insecurity and displacement directly constrained workforce deployment and retention. This scarcity was most acute in Haiti and Syria, where entire regions reportedly lacked a single CAMH specialist, while Lebanon and Colombia had stronger training capacity but continued to lose specialists to brain drain, private practice or NGO employment. In one instance, an informant in Syria mentioned that the scarcity was so acute that NGOs trained engineers to deliver structured psychosocial interventions in the absence of any psychology-trained workforce. In Haiti, informants noted that an already severe baseline shortage was critically exacerbated by the US humanitarian parole programme, which triggered a rapid exodus of medical professionals and left hospitals nearly empty. In Lebanon, the economic collapse reportedly accelerated the emigration of senior clinicians and supervisors, reducing the capacity for supervision and professional development.

Second, across contexts, insecurity, low remuneration, delayed payments and short-term contracts produced high turnover, further eroding supervision capacity and institutional memory. Donor-funded projects and trainings became central features of the labour market and, in some settings, were among the few predictable sources of income. Across contexts, informants noted that these trainings rarely translated into sustained service provision because funded posts, career pathways and supervision budgets did not exist to absorb trained individuals, reinforcing a cycle in which capacity was repeatedly built and then lost.

Third, humanitarian logics shaped what kind of workforce development was prioritized. Donors rewarded rapid, visible scale measured in beneficiary numbers over sustained clinical capacity, creating incentive structures that favoured short-term, low-intensity PSS while marginalizing complex case management, supervision and referral continuity. Across all four contexts, this resulted in a workforce whose distribution, retention and institutional embedding were structurally undermined, creating what was described as a “pyramid with no top”. Within this constrained landscape, task-shifting emerged as the dominant delivery model in all four countries. The case for task-shifting in mental health has been extensively documented, with studies from sub-Saharan Africa, South Asia and Latin America demonstrating that non-specialist cadres can deliver structured psychological interventions with adequate fidelity and effect when supported by clear protocols and supervision.Footnote ⁴⁶ Notably, while task-sharing implies a designed redistribution of functions with clear scopes, supervision and escalation, many informants noted that chronic scarcity and project-based service delivery often collapses that design intent, so task-sharing becomes task-shifting in practice, with non-specialists absorbing expanded responsibilities without stable supervision, funded roles or functioning referral pathways. This was visible across contexts, with non-specialist cadres delivering most first-line CAMH support through schools, primary health care and protection platforms, often guided by mhGAP and nationally endorsed manuals that provided a shared technical frame under conditions of extreme scarcity. Critically, however, to make these global frameworks and tools operational across these settings, technical actors often developed locally specific tools, training methodologies and cultural adaptations that are worth highlighting for practitioners working in comparable contexts. In Lebanon, the NMHP contextualized mhGAP-oriented modules into national packages of care aligned with available human resources and endorsed by professional bodies, helping to legitimize uptake across primary health-care facilities; practitioners also used community cognitive interviewing to adapt digital interventions such as the Step-by-Step programme, ensuring cultural resonance before rollout. In Syria, WHO used mhGAP as the primary standardization tool to integrate mental health into primary health-care facilities across multiple governorates, promoting a shared technical baseline in an otherwise fragmented humanitarian landscape. Previously, actors also piloted a cascade training approach in which a small group of master trainers trained front-line workers on MHPSS responses, supported by a customized bilingual handbook that unified training methodology and made international guidelines compatible with the Syrian context, improving coherence across territories and ministries.Footnote ⁴⁷ Additionally, in Haiti, practitioners found that when mental health duties were simply added to the existing workloads of polyvalent community health workers, it was experienced as “too burdensome”, forcing programmes to pivot to creating dedicated, mental-health-specific community health worker roles.Footnote ⁴⁸ Where generic screening tools were inadequate for capturing local expressions of distress, practitioners developed the Zanmi Lasante Depression Symptom Inventory, a locally validated screening and symptom-tracking tool tailored to Haitian cultural idioms that was embedded directly into community health worker workflows, demonstrating that sustainable task-shifting in crisis settings may require investment in locally developed measurement infrastructure, not only in intervention delivery.

Despite these adaptations, practitioners in Lebanon, Syria and Haiti emphasized the limited applicability of general population frameworks like mhGAP to CAMH. National training packages were widely described as adult-centric, often reducing CAMH to minimal content and leaving services insufficiently designed around children’s unique developmental and psychosocial needs. As a result, child-specific interventions such as HAT, EASE or Bloom were often introduced as supplementary layers. At the same time, insufficient guidance on scopes of practice and role boundaries, especially within protection and education systems, generated persistent ambiguity among many informants. Social workers, child protection staff and non-specialist providers especially reported uncertainty over when and how to intervene in cases involving severe CAMH needs, navigating complex clinical presentations with unclear limits on their authority. Similar concerns were expressed in Colombia, where uptake of mhGAP among primary care providers was described by some informants as uneven and incentives to assume additional mental health responsibilities as limited.

Across contexts, these conceptual and operational limits were compounded by weak supervision and fragile referral systems. Training frequently did not translate into sustained service provision because funded posts were absent, supervision was inconsistent and escalation pathways were poorly defined. As a result, systems became increasingly effective at identifying distress while remaining unable to manage complexity over time.

Implementation capacity was therefore clustered around specific anchors and delivery platforms, producing pockets of effectiveness rather than system-wide coverage. In Lebanon, multilayered capacity developed across the continuum of care but remained spatially concentrated, reinforced gaps in specialized services, and lacked strong referral mechanisms across sectors. In Colombia, mobile psychosocial teams under PAPSIVI temporarily overcame geographic exclusion by taking services to areas where professionals were unwilling or unable to settle. In Haiti, the Zanmi Lasante 5x5 model demonstrated that structured task-shifting paired with clear clinical pathways and specialist supervision could deliver care for severe conditions despite the near-total absence of psychiatrists. In Syria, standardized manuals enabled thousands of non-specialists across fragmented territories to deliver bounded interventions with some consistency. Yet across all four countries, these arrangements remained heavily dependent on external financing and coordination.

Despite these constraints, limited but meaningful efforts at workforce institutionalization emerged, most consistently in schools and learning spaces. Lebanon’s school counselling cadre, Syria’s school counsellors and Colombia’s psico-orientador (psychological counsellor) role provided entry points for identifying psychosocial distress and normalizing help-seeking, embedding a named, recurring mental health related function within State systems. Haiti historically lacked a comparable civil service role, relying almost entirely on task-shifting to teachers and child protection committees, with only recent pilot efforts to place psychologists in selected schools. The extent to which these positions have been resourced and integrated into national systems, linked with referral systems and equipped for continuity of care has varied considerably. Informants in Syria, Lebanon and Haiti described increasing ministerial efforts to move toward clearer role definition and standardization of school-based mental health roles, competency frameworks and linkages between education and health systems, often led by the Ministries of Education in partnership with other ministries and non-State partners. While these efforts are still taking shape, several informants reflected that progress on this front reflected a shared recognition that “without something fixed in the system, everything stays temporary”.

So what does this all mean? Strategic considerations for key actors

The findings presented in this paper carry implications that can extend beyond the four case studies. Across contexts, the conditions that enabled CAMH to gain and sustain political traction were not simply shaped by technical solutions, but were actively produced by the politics of health governance and by different actors making deliberate choices under constrained conditions. The following section is not intended to consolidate prescriptive recommendations – given the considerable variation in governance contexts, State capacity, conflict dynamics and humanitarian operating environments, no single playbook applies. Instead, these considerations, grounded in the patterns that recurred across the four settings studied here, are offered as entry points for different actor communities to contextualize and build on in their own settings.

Strengths and limitations of the study

This study has several notable strengths. The breadth and depth of primary data, drawing on ninety-three key informant interviews across four countries alongside systematic document review, provides a rich empirical foundation for cross-national comparison. The deliberate inclusion of four contextually distinct settings spanning different regime types, conflict trajectories, governance arrangements and humanitarian environments strengthens the analytical rigour of the findings, allowing patterns to be identified across cases while preserving attention to context-specific variation. The combination of virtual and in-person interviews, conducted in multiple languages, enabled access to informants across diverse geographic and institutional locations, including in settings where in-person research access is constrained by insecurity. The use of a consistent analytical framework across all four countries further strengthens comparability, allowing findings to speak to broader questions of CAMH institutionalization beyond any single context.

At the same time, several limitations should be acknowledged. The informant sample, while deliberately diverse across sectors, institutional levels and countries, was shaped by the practical constraints of access and willingness to participate. Informants were predominantly drawn from institutional actors within government, UN agencies, NGOs and academia, while community and grassroots voices, including those of children, families, and front-line workers in the most marginalized or insecure areas, are less fully represented. This introduces a risk of information bias toward the perspectives of actors with the greatest institutional visibility and access, who may have their own unique vantage points and incentives for different responses. Additionally, while the cross-national comparative design is a strength, it also introduces interpretive challenges. Differences in how interviews were conducted across countries, including variation in language, cultural context, interviewer positionality and translation processes, may have introduced inconsistencies in how questions were understood and answered, despite efforts to standardize the approach. Finally, the institutional positionality and reflexivity of the research team within and adjacent to UNICEF and academic institutions that are themselves shaping CAMH governance in some of the study countries represents both a strength and a limitation. Institutional proximity facilitated access to informants and documents that might otherwise have been difficult to obtain and enabled contextual knowledge that deepened interpretation, but at the same time, it may have shaped which questions were asked, which framings felt natural, and how informants positioned themselves in interviews. Readers should interpret findings with awareness that institutional proximity may have shaped both access and framing, even as the team actively worked to maintain analytic independence.