Impact statement
Despite suicide being a leading cause of death worldwide, many countries continue to face challenges providing quality care for people at risk. This paper presents learnings from six countries implementing the World Health Organization’s (WHO) Special Initiative for Mental Health (SIMH) and its use of the Mental Health Gap Action Programme (mhGAP). By documenting how mhGAP has influenced suicide prevention efforts, this work offers insights that may guide governments, partners and implementers seeking to integrate suicide prevention into broader mental health systems. Findings highlight that mhGAP training has consistently built capacity to identify, manage and follow up with individuals at risk of suicide. It shows how mhGAP training can improve facility work towards strengthened suicide prevention, increase suicide prevention as a health priority and foster collaboration. The results point to both progress and gaps: while mhGAP strengthens clinical response and service delivery at individual, facility and community levels, system-level actions such as sustainable financing, structured supervision and national surveillance require further investment and policy engagement. The implications of this work are global. The learnings presented can inform future guidance, help countries refine national suicide prevention strategies and promote donor investments targeting mental health system strengthening. By raising voices from mhGAP-trained health workers and consolidating lessons from real-world implementation, this paper provides actionable knowledge to accelerate progress towards reducing suicide mortality.
Introduction
Suicide prevention is explicitly recognised as a global health priority. There is a dedicated indicator (3.4.2) to reduce suicide mortality in the Global Goals (UN, 2015) and a related target in WHO’s Comprehensive Mental Health Action Plan 2013–2030 to reduce the global suicide rate by one-third by 2030 through system-wide and community-based mental health reform (WHO, 2021a).
The World Health Organization (WHO) has contributed significantly to advancing suicide prevention, with initiatives such as the Mental Health Gap Action Programme (mhGAP) and the LIVE LIFE suicide prevention implementation guidance/initiative framework (“LIVE LIFE”) (WHO, 2021b). mhGAP provides clinical guidance for non-specialist providers to deliver mental health care in low-resource settings, including for people with suicide risk (WHO, 2016). LIVE LIFE outlines four evidence-based interventions for national suicide prevention: limiting access to means, promoting responsible media reporting, fostering life skills among adolescents, and strengthening early identification and care for at-risk individuals. These interventions are designed to be supplemented with six cross-cutting foundations: situation analysis, multi-sectoral collaboration, awareness raising, capacity building, financing and surveillance, monitoring and evaluation. Further, WHO’s LIVE LIFEs interventions are supported by policy guidance, including the WHO Resource for Media Professionals (WHO, 2017) and the WHO Policy Brief on Decriminalizing Suicide (WHO, 2023).
At the same time as WHO’s focus on suicide prevention, and as part of the WHO’s 13th and 14th General Programme(s) of Work (GPW13 2019-2023/4 (WHO, 2019); GPW14 2025-2028; WHO, 2025), the WHO has undertaken broader work on mental health, brain health and substance use. In 2019, WHO launched its mental health flagship programme, known as the WHO Special Initiative for Mental Health (SIMH), aiming to increase access to mental health services for 100 million more people (for details about SIMH, see Kestel et al. [Reference Kestel, Chisholm and Schafer2025]). At the time of this paper, WHO’s SIMH was working in Argentina, Bangladesh, Cambodia, Ghana, Jordan, Nepal, Paraguay, the Philippines, Ukraine and Zimbabwe, with each country in different phases of implementation. In these contexts, suicide prevention has increasingly emerged as a government priority and sought to be embedded among broader efforts to strengthen mental health systems, and is featured in country-specific SIMH designs (Sala and Schafer, Reference Sala and Schafer2025). These system-level approaches, including the expansion of mhGAP and LIVE LIFE as part of systems transformation efforts, follow WHO recommendations in the World Mental Health Report (2022).
Mental health services to support individuals experiencing suicide ideation or self-harm are critical for suicide prevention (Fleischmann et al., Reference Fleischmann, Arensman, Berman, Carli, De Leo, Hadlaczky, Howlader, Vijayakumar, Wasserman and Saxena2016). In low-resource settings, where access to specialist mental health services is limited, the mhGAP Intervention Guide offers a practical means to deliver such support through trained non-specialist health workers (Keynejad et al., Reference Keynejad, Dua, Barbui and Thornicroft2018). mhGAP has been adopted by over 100 countries as a tool to scale up services for priority conditions, including suicide behaviours, in non-specialist settings (WHO, 2018).
mhGAP has been a foundational tool in WHO’s SIMH countries to integrate mental health services into primary health care settings, and all countries included the dedicated self-harm/suicide module in their mhGAP trainings. As Fleischmann and Saxena (Reference Fleischmann and Saxena2013) suggested, mhGAP offers a structured approach to strengthen suicide prevention by guiding non-specialist providers through assessment, management and follow-up for individuals at risk. While WHO (internal) SIMH country reports do not explicitly attribute an increased suicide prevention focus to mhGAP trainings and implementation, they frequently reference it alongside broader systems-level suicide prevention activities, highlighting its central role in suicide prevention capacity development. To date, 78,000 individuals have received various mental health trainings in SIMH countries, with at least 51% of those receiving mhGAP-based intervention or community awareness training (WHO, 2025, SIMH monitoring data and communications). mhGAP is the SIMH’s main platform for scaling up workforce competencies to support self-harm and suicide cases. Evidence from outside SIMH contexts reinforces this mhGAP and suicide prevention link: in Mexico, mhGAP training significantly improved primary care providers’ knowledge and readiness to identify and manage depression and suicide risk (Robles et al., Reference Robles, Lopez-Garcia, Miret, Cabello, Cisneros, Rizo, Ayuso-Mateos and Medina-Mora2019). Similarly, in the Kyrgyz Republic, an mhGAP training pilot was associated with a 17% increase in the detection of depression and suicide, further demonstrating its potential to strengthen early identification (Pinchuk et al., Reference Pinchuk, Yachnik, Kopchak, Avetisyan, Gasparyan, Ghazaryan, Chkonia, Panteleeva, Guerrero and Skokauskas2021).
These emergent patterns about mhGAP from Mexico and the Kyrgyz Republic, and implementation experience from the WHO’s SIMH, suggest a growing recognition of mhGAP as a potentially strategic facilitator for national suicide prevention. The anecdotal strength of this linkage has attracted attention within the WHO SIMH and presents a compelling case for deeper documentation and learning. Documenting these learnings could shed light on the ways LIVE LIFE interventions are evolving in SIMH countries as an enabler of national plans and work towards suicide prevention. In Nepal, for example, a suicide helpline that was initially supported by WHO as part of SIMH work – alongside expansion of mhGAP-based services in primary healthcare settings – is now fully operated and funded by the government. In Ghana and the Philippines, SIMH work with mhGAP has assisted the development of community-based initiatives that have engaged teachers, traditional leaders and local health boards in suicide prevention – underscoring the importance of cultural relevance and local ownership in successful implementation.
Leveraging this Global Mental Health special edition on self-harm and suicide, WHO availed this opportunity to explore and document learnings about ways mhGAP implementation in SIMH countries has contributed to suicide prevention. We sought to gather insights on the intersection of how the SIMH, mhGAP and LIVE LIFE core pillars (i.e., cross-cutting foundations) converge during real-time implementation.
Our exploratory examination investigates how mhGAP training and system integration have facilitated responses to suicide and self-harm, and the conditions under which these responses emerged. These informally captured learnings are intended to explore the perspectives of mhGAP-trained health workers and how they regard mhGAP and its self-harm/suicide learnings as having advanced suicide prevention efforts. Drawing on these reflections, we consider lessons for integrating suicide prevention into national efforts to scale up mental health care under universal health coverage through mhGAP training.
The working hypothesis for this learning paper was that mhGAP training and integration in the SIMH has contributed to strengthening suicide prevention action and the operationalisation of some, or all, of the LIVE LIFE interventions and/or cross-cutting foundations. The paper aims to contribute to global learnings about systems-level suicide prevention by documenting how WHO SIMH-supported interventions, particularly integration of mhGAP, have been contributing to self-harm and suicide prevention. In doing so, it reinforces the imperative of treating suicide as a public health and development priority, and underscores WHO’s continued role in supporting countries towards resilient, inclusive and rights-based mental health systems.
Method
We used a descriptive survey incorporating quantitative and qualitative components to explore how mhGAP implementation in the WHO SIMH may be complementing suicide prevention efforts across six SIMH countries. While each of the participating countries had, to a small extent, implemented mhGAP before the SIMH, substantial mhGAP scale-up as part of SIMH began as follows: Bangladesh (since 2021), Ghana (since 2023), Jordan (since 2010), Ukraine (since 2019), Nepal and Zimbabwe (since 2023). Survey responses from Paraguay (n = 1) and Argentina (n = 4) were excluded from the analyses due to insufficient responses, and the Philippines (n = 12) was excluded because the survey denominator was unknown. Cambodia was excluded because its SIMH work was still in the design phase.
From WHO’s country office colleagues, the survey was electronically shared with mhGAP trainees, without a targeted sampling approach. The survey remained open for 39 days. Estimated country-level response rates were: Bangladesh 8% (12/150), Jordan 10.5% (21/200), Ukraine 25% (44/150–200), Ghana 19% (63/333), Nepal 58% (23/40) and Zimbabwe 33% (132/400). Approximate denominators are reported based on how many mhGAP-trained providers received the survey link, via WhatsApp groups and similar channels; Ukraine used a snowballing approach, hence a response rate range.
WHO approached data collection as part of learning about SIMH implementation work and to monitor how mhGAP training was influencing the application of the mhGAP’s self-harm/suicide module. In line with international guidelines where activities relate to programme monitoring, evaluation and service improvement are exempt from formal institutional ethics review, ethics approval was not sought at the outset. Nonetheless, details about the survey and intended use of data were provided as part of informed consent before respondents accessed survey questions. Voluntariness (opt-in) and anonymity (except for country of work) were emphasised and agreed electronically. The survey was presented in English; however non-English-speaking respondents were further instructed to electronically translate the tool and could respond in the languages commonly spoken across SIMH countries (namely Ukrainian and Bangla). Non-English responses were electronically translated to English for thematic analysis. Due to limited capacity, no translation validation or back-translations were applied. Following a larger-than-expected response, the dataset was re-evaluated against international ethical standards and determined that, due to no intervention being applied and no identifiable or sensitive information being shared, ethics approval for publication of information was not required.
The survey combined seven ordinal Likert-scale items (variables: strongly agree, agree, disagree and strongly disagree) and four qualitative questions. The Likert-scale items invited respondents to reflect on the extent to which mhGAP training: (1) improved their ability to identify and support people at risk of suicide; (2) increased confidence in managing suicide risk in daily clinical work; (3) strengthened facility-level support for individuals with suicidal thoughts or self-harm; (4) improved access to tools, referral options and supervision; (5) elevated suicide prevention as a health priority within their facility or district; (6) influenced services outside the health sector (e.g., education and community); and (7) could be sustained through existing country systems and resources. Responses to the Likert-scale questions were analysed for descriptive purposes. The qualitative questions were themed towards specific, influential, observed and system-level actions, collecting insights about the impacts of mhGAP training at different levels of the health system:
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1. Individual level: Specific actions. Since completing mhGAP training, have you taken any specific actions related to suicide prevention in your clinical work?
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2. Individual and facility level: How training changed daily practices or views. In what ways has mhGAP training influenced how suicide prevention is addressed at your health facility or in your daily work?
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3. Team and/or facility level: Changes observed in team or facility behaviour. Have you observed any changes in how your facility or team responds to people at risk of suicide or self-harm?
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4. System-level factors: What helps or hinders suicide prevention in your context? What system-level factors have supported or limited your ability to provide care to people at risk of self-harm or suicide?
Of the 295 respondents, 13 (4%) omitted the qualitative questions (2 in Zimbabwe, 4 in Ukraine, 3 in Jordan, 3 in Ghana and 1 in Bangladesh), leaving 282 qualitative responses for thematic analysis. To structure thematic analysis, we used the LIVE LIFE interventions as an organising framework. Employing a deductive approach, with some of the flexibilities of inductive thematic analysis (e.g., Braun and Clarke, Reference Braun and Clarke2006), the analyses benefited from the steps outlined in Fife and Grossner’s (Reference Fife and Gossner2024) primer on Gilgun’s (Reference Gilgun, Fortune, Reid and Miller2013) deductive qualitative analysis.
Both authors (LL and AS) explored responses for familiarity. Responses were coded by question by the first author (LL) to establish a thematic structure. Codes and themes were checked and adjusted by the second author (AS); with less clear themes (e.g., those with multiple possible interpretations, titles or descriptions) discussed and reconstructed based on joint-author agreement. Thereafter, agreed themes were mapped against the LIVE LIFE cross-cutting foundations and interventions, allowing for responses that reflected multiple elements being included in multiple themes. In the qualitative analysis, approximate quantifiers (e.g., “more than,” “around,” “>” and “≈”) were used when responses contained overlapping ideas. For example, “lack of care,” “lack of transportation” and “difficult access to remote areas” were grouped into a higher-level theme of “foundational resources,” making it neither feasible nor appropriate to claim a single precise count for each statement. Therefore, estimates are reported to transparently reflect this interpretive approach.
Results
Descriptive quantitative analysis
Based on estimated denominators, the overall survey response rate was 22–23%. Shown in the distribution of responses by country, Figure 1 illustrates Zimbabwe (n = 132), Ghana (n = 63) and Ukraine (n = 44) had higher response rates compared with Bangladesh, Jordan and Nepal. Although Zimbabwe contributed the largest absolute number of responses (n = 132), its response rate (33%) was comparable to or lower than that of other countries (e.g., Nepal 58%).
mhGAP-trained health care worker survey responses by country (n = 295).
Figure 2 shows the distribution of responses across the seven Likert-scale statements. Across most items, respondents reported very high levels of agreement. The strongest endorsement was for the individual-level statements “The mhGAP training improved my ability to identify and support people at risk of suicide” and “I feel more confident managing suicide risk in my daily clinical work,” both with the highest numbers of “strongly agree” responses and very few disagreements. Items relating to facility-level change, such as improved support for individuals with suicidal thoughts and increased prioritisation of suicide prevention, also showed a clear majority agreement, albeit with slightly more respondents selecting “disagree” or “strongly disagree” in comparison to the individual-level items. Agreement was lowest for the two system-wide statements: “mhGAP training has influenced services outside the health sector” and “My country has the systems and resources to sustain suicide prevention actions beyond mhGAP training.” These two items had the highest counts of disagreement, with the sustainability item showing the largest combined disagreement (n = 126).
The extent of agreement of mhGAP-trained health care workers (n = 295) in relation to the changes mhGAP provided for strengthening suicide prevention at individual, facility and systems levels.
Figure 2. Long description
The chart displays responses from 295 health workers across four categories: Strongly Agree (blue), I agree (orange), I disagree (grey), and Strongly disagree (yellow). The x-axis represents percentage from 0 to 100 percent.
* Statement 1 (Top): My country has the systems and resources to sustain suicide prevention actions beyond m h G A P training. Data: 41 strongly agree, 124 agree, 108 disagree, 18 strongly disagree.
* Statement 2: I believe that m h G A P training has influenced services outside the health sector. Data: 93 strongly agree, 165 agree, 27 disagree, 6 strongly disagree.
* Statement 3: Since the m h G A P training, responding to self-harm and preventing suicide is now treated as a higher health priority in my facility or district. Data: 109 strongly agree, 159 agree, 17 disagree, 8 strongly disagree.
* Statement 4: The m h G A P training has helped us to access the tools, referral options, and supervision needed to provide care to people at risk of self-harm or suicide. Data: 121 strongly agree, 158 agree, 8 disagree, 7 strongly disagree.
* Statement 5: Since the m h G A P training, my facility now provides better support for people experiencing suicidal thoughts or self-harm. Data: 106 strongly agree, 166 agree, 15 disagree, 8 strongly disagree.
* Statement 6: Since the m h G A P training, I feel more confident managing suicide risk in my daily clinical work. Data: 144 strongly agree, 136 agree, 5 disagree, 8 strongly disagree.
* Statement 7 (Bottom): The m h G A P training improved my ability to identify and support people at risk of suicide. Data: 186 strongly agree, 99 agree, 0 disagree, 10 strongly disagree.
Thematic qualitative analysis
Due to Zimbabwe contributing the largest absolute number of survey and qualitative responses (n = 132), thematic codes and patterns were first assessed to ascertain potential undue influence on the overall findings. Compared with other countries, Zimbabwe health workers reported fewer statements about systems to sustain suicide prevention, and more comments about the positive influences of mhGAP in relation to suicide prevention. However, these differences were insubstantial to the overall data set, and thematic findings were consistent across all six countries.
The coding phase of the qualitative analysis derived two clusters of ideas for questions 1 (Since completing mhGAP training, have you taken any specific actions related to suicide prevention in your clinical work?) and 3 (Have you observed any changes in how your facility or team responds to people at risk of suicide or self-harm?), and three clusters for questions 2 (In what ways has mhGAP training influenced how suicide prevention is addressed at your health facility or in your daily work?) and 4 (What system-level factors have supported or limited your ability to provide care to people at risk of self-harm or suicide?), presenting a total of 10 initial themes identified. These 10 codes are presented in Figure 3, which represents the most frequently occurring codes for the four qualitative questions.
Initial and most prevalent codes from qualitative thematic analysis by question.
Figure 3. Long description
The diagram consists of four vertical columns, each topped with an orange header box containing a research question. Sub-codes are listed in white boxes below each header, connected by a vertical line.
Column 1, Question 1. Since completing m h G A P training, have you taken any specific actions related to suicide prevention in your clinical work?
- 1.1 Early Identification and Clinical Action. Includes screening, assessment, follow-up, case management, counselling, and social support.
- 1.2 Community Engagement and Awareness. Includes community outreach, sensitization, and psychoeducation.
Column 2, Question 2. In what ways has m h G A P training influenced how suicide prevention is addressed at your health facility or in your daily work?
- 2.1 Strengthened Clinical Practices. Includes use of m h G A P tools, early identification, and counselling.
- 2.2 Expanded Service Delivery Capacity. Includes service provision, integration, and referral.
- 2.3 Elevated Prioritization and Advocacy. Includes staff empowerment and advocacy.
Column 3, Question 3. Have you observed any changes in how your facility or team responds to people at risk of suicide or self-harm?
- 3.1 Systems and Practices. Includes service changes, documentation, safe planning, and family involvement.
- 3.2 Human Capacity and Attitudes. Includes skills, collaboration, and stigma reduction.
Column 4, Question 4. What system-level factors have supported or limited your ability to provide care to people at risk of self-harm or suicide?
- 4.1 Service Inputs - Financial investments required. Includes lack of human resources, lack of resources, medicines, infrastructure, transportation, and logistics.
- 4.2 Service Delivery - Procedures. Includes referral pathways, supervision, bureaucracy, and guidelines/protocols.
- 4.3 Collaboration and Stigma Reduction. Includes leadership support and prioritization.
When comparing themes across the four questions, considerable overlap was observed. For example, Community Engagement and Awareness (1.2), Elevated Prioritisation and Advocacy (2.3), Human Capacity & Attitudes (3.2), and Collaboration and Stigma Reduction (4.3) all focused on similar ideas of community participation, stigma reduction, leadership engagement and prioritisation of suicide prevention actions.
The vast majority of respondents (n = 245) reported changes to the third facility-level question (Have you observed any changes in how your facility or team responds to people at risk of suicide or self-harm?). Only 4 mhGAP trainees described minimal to some changes at the facility level, and 22 health workers reported no changes at all. This distribution is an important trend, underscoring variation in experiences of progress across settings.
To further present a coherent picture of the main themes, the question-level concepts were consolidated to arrive at a 4-level thematic construct, with the 10 question-level concepts provided as subthemes (presented in Figure 4). The only stand-alone subtheme was (4.1) Service Inputs – Financial investments required. This theme uniquely captured inputs that require monetary provisions and reflected either barriers (e.g., lack of staff, medicines, transport and infrastructure) or new inputs that emerged as a result of mhGAP training.
Main themes describing the influences of mhGAP training on suicide prevention at individual, facility and system levels.
Figure 4. Long description
The diagram presents four themes, each with a specific focus and sub-points.
Theme 1. Clinical action and improved services. Focus. Direct care for people at risk.
• 1.1 Early Identification and Clinical Action
• 1.2 Strengthened Clinical Practices
Theme 2. Awareness, advocacy, and collaborative capacity. Focus. Community engagement, stigma reduction, leadership, prioritization.
• 1.2 Community engagement and awareness
• 2.3 Elevated prioritization and advocacy
• 3.2 Human capacity and attitudes
• 4.3 Collaboration and stigma reduction
Theme 3. Service organization and delivery. Focus. How services are structured, coordinated, and monitored.
• 2.2 Expanded service delivery capacity,
• 3.1 Systems and practices,
• 4.2 Service delivery procedures
Theme 4. Foundational resources. Focus. Inputs required to sustain actions.
• 4.1 Service inputs financial investments required
Several patterns emerged from this qualitative analysis. In response to questions 1, 2 and 3, Clinical action and improved services was the most regularly reported theme. Screening and referral were mentioned by nearly half of respondents in question 1, indicating that early risk detection appears to be the most consistently applied skill following mhGAP training. Early identification (question 2) was another frequently coded item (nearly 90 responses) and was commonly paired with counselling or psychoeducation, possibly signifying a shift towards psychosocial and biopsychosocial approaches. Follow-up also appeared frequently in responses to all four questions, suggesting continuity of care beyond initial identification.
#285 from Nepal – mhGAP training has significantly improved my ability to identify individuals at risk of suicide early and provide timely intervention. It has strengthened my communication skills for sensitive counseling and taught me structured assessment methods.
#178 from Jordan – Better Follow-up: There is a more structured approach to follow-up care, ensuring patients at risk continue to receive necessary support.
Practices such as safety planning (question 3) and supervision (question 1) were only occasionally mentioned as actions introduced after the training; however, when asked in question 4 about barriers or supports, supervision was one of the most frequently cited needs across all countries (nearly 50). This suggests that while these practices exist, they are not yet widely integrated into routine care and are perceived by health workers as critical for sustaining quality suicide prevention services.
Awareness, advocacy and collaborative capacity appeared prominently in response to questions 1 and 2. Staff empowerment/increased soft skills (>30 respondents) and greater awareness/prioritisation of suicide prevention (>45 respondents) after the training were frequently reported in question 2, suggesting that mhGAP training influenced facility culture and made suicide prevention a higher priority.
Some respondents (>12) referenced leadership buy-in, policy-level shifts (n = 1) and participation in local awareness campaigns (≈15), pointing to early signs of community-level advocacy and ownership. Even though awareness-raising efforts beyond campaigns were noted by health workers in each country, their responses did not describe or explain said approaches.
Improved collaboration/cooperation (≈80) was also frequently mentioned in question 3 responses. This was interpreted to suggest that mhGAP training encouraged team-based approaches to mental health care and services. For example, training of peers was reported by two respondents to question 1, mentioning informal capacity-building and leadership roles among mhGAP-trained health workers. Stigma/bias was another recurring theme (>20), with some respondents perceiving reduced stigma in their facilities, while others described it as an ongoing barrier that limited help-seeking and intervention.
#125 from Ukraine – We are now not afraid and know what to do to begin with.
#38 from Zimbabwe – Yes there was reinforcement of multi-disciplinary approach. There is now active participation in all departments involved in the care and inter departmental collaboration has improved.
#6 from Zimbabwe – Minimal changes has been noted as some nurses still have an attitude towards parasuicide patients.
#225 from Ghana -Reduced stigma of people at risk by health staff. Increased empathy for people at risk of suicide.
Service organisation and delivery patterns were particularly visible in responses to questions 2 and 3. Service-related codes, including service provision, integration and quality improvements, pointed to operational changes beyond individual clinician skills. At the same time, responses to question 4 highlighted ongoing gaps in referral systems (more than 25 specifically on gaps within referral). For example, unclear referral pathways, indicating at least one area where further system strengthening is needed. Documentation and confidentiality practices introduced were occasionally referenced (>5), showing that some facilities have started to formalise processes such as case reporting and privacy safeguards.
#48 from Zimbabwe – Integration of suicide prevention into routine care, suicide risk assessments have become a standard part of mental health and general assessments.
#179 from Jordan – we now respond more systematically to individuals at risk, including better documentation and timely referrals.
#304 from Bangladesh – I separated a room in my facility only for counseling to suicide prone people.
Foundational resources were most strongly represented in the system-level question (question 4). Numerous health workers acknowledged lack of resources (>90), but overwhelmingly, respondents cited specific issues, including lack of staff and the need for further training (>30); access to medicines, infrastructure and transport/logistics were additional and persistent barriers to effective suicide prevention action. Several responses noted inadequate privacy, such as counselling being conducted in open spaces, which can compromise confidentiality and discourage service use. At least 10 health care workers reported lack of time as a barrier to providing better quality services, pointing to workload pressures as another systemic constraint. Infrastructure improvements or new inputs that emerged after mhGAP implementation also implied that training may have contributed to local advocacy for resources. Such statements contrasted with responses about inadequate infrastructure to provide services.
#23 from Zimbabwe -The system is very supportive however transport and medication shortages are the only and major setbacks.
#179 from Jordan – high patient load, and limited time for proper assessment and follow-up.
#145 from Zimbabwe – …facilitation of resources allocation has improved.
Emerging themes
In a final step of analysis, the four consolidated themes were mapped against the LIVE LIFE suicide prevention implementation framework. Since LIVE LIFE’s cross-cutting foundations are intended to enable and sustain the implementation of all four LIVE LIFE interventions, these were mapped in parallel, allowing a comprehensive view of contribution areas and a structured view of where SIMH-supported mhGAP activities appear to have contributed to suicide prevention action. This is presented in Table 1. Of note, the mhGAP trainee feedback and analysed themes did not address the LIVE LIFE interventions for responsible media reporting and limiting access to means of self-harm/suicide, and the analyses did not relate to the LIVE LIFE cross-cutting foundations for situation analysis. Regarding the surveillance, monitoring and evaluation pillar, the LIVE LIFE framework highlights the importance of consistently collecting and reporting data on self-harm and suicide, integrating it into national health information systems. While respondents did not explicitly report contributions at the national surveillance level, some elements were observed at the facility and service levels, including documentation of cases, reporting mechanisms and the introduction of confidentiality practices. This is particularly relevant given that under-reporting can result from limited access to health care or financial barriers such as restricted health insurance coverage, which may prevent individuals from seeking support following suicide attempts. Ensuring universal health coverage is therefore vital, both for enabling care and for improving the completeness of suicide and self-harm surveillance data.
Matrix of high-level themes from mhGAP implementation in SIMH countries, mapped to LIVE LIFE interventions and cross-cutting foundations
Table 1. Long description
The table consists of four main rows under three column headers.
* Row 1: High-level theme is Clinical action and improved services (subthemes 1.1, 2.1). Relevant LIVE LIFE interventions include early identification, management, and follow-up of suicidal behaviors through screening, assessment, counseling, psychosocial support, m h G A P tools, and follow-up. Relevant LIVE LIFE cross-cutting foundations include capacity building for workforce skills in clinical management.
* Row 2: High-level theme is Awareness, advocacy and collaborative capacity (subthemes 1.2, 2.3, 3.2, 4.3). Relevant LIVE LIFE interventions are not specified. Relevant LIVE LIFE cross-cutting foundations include awareness raising and advocacy for prioritization and stigma reduction; multi-sectoral collaboration for leadership and intersectoral engagement; and capacity building for advocacy and communication skills.
* Row 3: High-level theme is Service organization and delivery (subthemes 2.2, 3.1, 4.2). Relevant LIVE LIFE interventions include early identification, management, and follow-up of suicidal behaviors through referral pathways, integration, supervision, and service protocols. Relevant LIVE LIFE cross-cutting foundations include surveillance, monitoring, and evaluation of referral and documentation data; and multi-sectoral collaboration for service integration.
* Row 4: High-level theme is Foundational resources (subtheme 4.1). Relevant LIVE LIFE interventions are not specified. Relevant LIVE LIFE cross-cutting foundations include financing for the allocation of staff, funds, infrastructure, medicines, and transport.
Shown in Table 1, mhGAP training in SIMH countries primarily supported the LIVE LIFE intervention on early identification, management and follow-up of suicide behaviours, and contributed to most of the LIVE LIFE cross-cutting foundations, apart from situation analysis.
Discussion and conclusion
This paper presents a synthesis of learnings from 6 of the 10 World Health Organization’s (WHO) Special Initiative for Mental Health (SIMH) countries, in response to an exploratory structured survey. Although results may not be generalisable, learning patterns emerging from mhGAP implementation support the working hypothesis that mhGAP training appears to contribute to the strengthening of national suicide prevention actions and operationalisation of some of the LIVE LIFE interventions and cross-cutting foundations. These insights may therefore inform future programming and dialogue on suicide prevention.
Results of these learnings suggest that in WHO SIMH countries, mhGAP training enhanced individual health worker capacity for early identification, management and follow-up of people presenting with self-harm/suicide behaviours, as well as community outreach or education about self-harm/suicide. At the team or facility-level, mhGAP also contributed to placing suicide as a higher priority for service delivery and transformed attitudes to reduce suicide-related stigma. At the broader [mental] health systems levels, the implementation and integration of mhGAP had less impact, but still contributed to several procedural improvements, such as establishing clearer referral pathways and improved case documentation practices, stronger multi-sectoral collaboration and leadership about suicide prevention. Although improvements at this systems level may be small, it may take more time for mhGAP to be fully embedded in routine service delivery. In addition to time, overcoming barriers will also require deliberate system-building, stronger policy frameworks and increased, sustained funding. At all levels (i.e., individual, facility and system), however, the potential impacts of mhGAP training towards suicide prevention remained wanting for greater financial investments and inputs.
The mapping of identified SIMH learning themes to the LIVE LIFE interventions and cross-cutting foundations demonstrated particularly strong alignment for mhGAP supporting the early identification, management and follow-up of suicide behaviours. Surveyed health workers reported increased confidence, enhanced skills in suicide risk management and improved ability to provide psychosocial support, illustrating a meaningful impact on individual-level capacity. This finding is consistent with mhGAP’s intended purpose of equipping non-specialist health workers with the knowledge and skills required to respond effectively to suicide risk, particularly in low-resource settings (Keynejad et al., Reference Keynejad, Dua, Barbui and Thornicroft2018). It further substantiates the position of Fleischmann and Saxena (Reference Fleischmann and Saxena2013) and results from the Mexico study by Robles et al. (Reference Robles, Lopez-Garcia, Miret, Cabello, Cisneros, Rizo, Ayuso-Mateos and Medina-Mora2019), as well as evidence from the Kyrgyz Republic (Pinchuk et al., Reference Pinchuk, Yachnik, Kopchak, Avetisyan, Gasparyan, Ghazaryan, Chkonia, Panteleeva, Guerrero and Skokauskas2021). The LIVE LIFE intervention for fostering the life skills of young people, and the cross-cutting foundation of raising awareness, was not directly reported in the survey responses; however, respondents reframed their involvement in such activities, and alignment for this wider community-level or educationally based part of suicide prevention in the theme labelled “Awareness, advocacy and collaborative capacity.”
The benefits of the mhGAP training went beyond individual-level impacts, according to themed responses from this learning survey. Respondents also described shifts at the facility level, such as stronger team collaboration, prioritisation of suicide prevention and greater readiness to tackle system-level suicide prevention, suggesting mhGAP may both strengthen the competencies of individual health workers as well as support institutional capacity for sustained suicide prevention action. This is consistent with results from the Keynejad et al. (Reference Keynejad, Dua, Barbui and Thornicroft2018) systematic review of mhGAP evidence, which showed mhGAP being used as a catalyst for stronger services, advocacy and innovative implementation approaches for a variety of mental health interventions.
In contrast to the alignment of mhGAP rollout with LIVE LIFE interventions, our learnings showed no contributions for mhGAP and the LIVE LIFE interventions related to restricting access to the means of suicide or media engagement, or for the cross-cutting foundation on situational analysis. This is understandable given such interventions do not always, or necessarily, include the same personnel trained in mhGAP. Similarly, with regards to surveillance, monitoring and evaluation. Although the documentation of self-harm/suicide cases at facility levels was highlighted by some health workers to have improved, the documentation was limited to reporting practices, case management needs and confidentiality measures, as opposed to the intended improvements of surveillance, monitoring and evaluation (in LIVE LIFE) at national levels.
The present survey findings indicated most contributions of mhGAP implementation to suicide prevention concentrated at the individual, facility and community levels. Contributions to national-level policy or legislation were rarely mentioned. As such, suicide prevention action in WHO SIMH countries appears to be advancing at the service levels, but further exploration beyond mhGAP-focused activities will be necessary to capture the full scope of system- and policy-level progress. Additional systematic research is warranted to ascertain the extent of reported improvements or quality of practices and procedures to which the learning results here imply.
Limitations
Framed as programmatic learnings from the WHO SIMH, the results from this survey should be used with caution. The authors – affiliated with WHO and the SIMH – acknowledge the potential for bias. Social desirability from WHO-trained health workers in mhGAP, who received the survey from WHO country office colleagues, may have also influenced survey responses. Further, cross-country contextual variation may limit the comparability of findings across settings.
Methodological limitations also constrain the results. For instance, no sampling framework or randomisation of participants was applied, the translation of the survey tool and responses (in Ukrainian and Bengali) was informal, and higher response rates from some countries were not statistically verified and may have skewed results. The lower-recorded responses from other SIMH countries may have also been a consequence of the survey being only distributed in English.
Irrespective of these limitations, these WHO SIMH learnings show potential as groundwork for further systematic studies related to the benefits of mhGAP implementation as part of suicide prevention efforts. Future learnings or studies might consider more inclusive methods, such as providing multilingual surveys and complementing them with in-depth interviews or focus groups, capturing not only health worker perspectives but also those of managers, policymakers and service users. More robust methodological approaches may also shed more light on mhGAP’s influence on suicide prevention.
Conclusion
Drawing on learnings from the WHO SIMH, this paper sought to understand how the integration of mhGAP has contributed to self-harm and suicide prevention action in WHO SIMH countries. The findings generate several relevant lessons for WHO and its partners as they support countries to integrate suicide prevention within mental health system strengthening efforts. These lessons may be summarised according to four qualitative themes identified from this investigation, noting that improvements could further enhance the benefits of mhGAP implementation and its relationship with suicide prevention.
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1. Clinical action and improved services: mhGAP has surfaced as a useful tool for improving the early detection and clinical management of self-harm/suicide behaviours. Strengthening mechanisms for ongoing clinical supervision and embedding safety planning into standard protocols would enhance sustainability and quality of care.
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2. Awareness, advocacy and collaborative capacity: mhGAP appears to support a shift in facility culture, normalising suicide prevention as a priority and reducing stigma. There is scope to leverage this momentum for broader intersectoral collaboration and community engagement, extending impacts beyond the health sector.
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3. Service organisation and delivery: Improvements were observed in referral pathways, documentation and service integration; however, gaps remain, particularly regarding unclear referral systems, lack of privacy for counselling and limited supervision. Linking mhGAP training to wider system reforms could address these gaps and promote more comprehensive service delivery.
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4. Foundational resources: Persistent shortages of staff, medicines, infrastructure and time were consistently reported as barriers to addressing self-harm/suicide, and mhGAP practices overall. These structural constraints underscore the need for sustained investment and resource mobilisation to enable health workers to apply the skills gained through mhGAP training.
Open peer review
To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2026.10177.
Data availability statement
The data that support the findings of this paper are available upon reasonable request from the corresponding author, Alison Schafer.
Acknowledgements
The authors thank the WHO Special Initiative for Mental Health (SIMH) country focal points and Regional Advisors for advancing mental health systems transformation in their countries, including suicide prevention, together with their teams and partners. Their support in sharing information and enabling mhGAP-trained health workers’ participation made these learnings possible. We are grateful to SIMH donors for their commitment to mental health system strengthening. Most importantly, we are grateful to the mhGAP-trained health workers who made this paper possible and contributed to global learning on suicide prevention by sharing their experience.
Author contribution
Both authors, L.L. and A.S., have made substantial contributions to the conception, design of the work, to the acquisition, analysis and interpretation of data. Both authors participated in drafting the manuscript. A.S.pproved the final version for publication. Alexandra Fleishmann reviewed the manuscript. Individuals who supported the work but did not meet the criteria for authorship have been recognised in the Acknowledgements.
Financial support
This exploratory study received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
Authors receive ongoing salary from the World Health Organization (WHO) and directly work on the WHO Special Initiative for Mental Health (SIMH). Lidiia Lukasevych is a WHO Consultant to the WHO SIMH and Alison Schafer is a WHO Staff member, leading implementation of the WHO SIMH.
Open access
Comments
This paper presents learnings from the WHO Special Initiative for Mental Health countries, documenting how mhGAP implementation has contributed to suicide prevention efforts.
This submission follows the kind suggestion of the Lead Guest Editor, Dr. Jerome T. Galea, who encouraged us to contribute SIMH-related learnings to this special edition. As noted in our earlier correspondence with the editorial team, we were also kindly granted an extension to the deadline to finalise and submit this paper till today.
We hope this manuscript will add value to the global discussion on self-harm / suicide prevention and mental health system strengthening.