Global Institute for Mental Health Innovations, Networking and Development
Mental Health Open ISSN 3122-1181 Vol. 2 (2026). Issue 1.
Learning Inside the System: What Community-Based MHPSS Practice in Pakistan Teaches Us About Global Mental Health Training {under peer review}
conceptual insights and critical reflections
Sumbal Gilani, School of Health and Wellbeing, College of Medical Veterinary & Life Sciences, University of Glasgow, United Kingdom (UK); https://orcid.org/0009-0008-0623-3258
Abstract
In this paper, the author argues that the pedagogical innovations called for in global mental health (GMH) education are not waiting to be designed; in many cases, they have already been built, tested against difficult realities, and quietly discarded from the international conversations simply because they weakly emerged from the Global South. Responding to the call by Karadzhov (2025) for the contextualised, collaborative and future-oriented approaches to GMH competency development, this paper draws on the author’s conceptual insights and critical reflections resulting from an extended practitioner experience in Pakistan to propose a model termed system-embedded pedagogy, an approach in which professional formation happens inside live service delivery systems rather than in preparation for them. Four interconnected MHPSS initiatives are examined through an explicit pedagogical lens: the I Support my Friends peer support programme for adolescents; sports-based mental health programming; the establishment of community child protection systems and district child protection units (DCPUs) in Khyber Pakhtunkhwa; and the Child Protection Van (CP Van) outreach model. Each case is mapped onto a recognised pedagogical mode, service and experiential learning, reflective supervision, peer-led and collaborative learning, and problem-based learning, to demonstrate what these approaches look like when they are operationalised within a functioning, resource-constrained, community-anchored system. The paper argues that GMH academic curricula must move from treating field experience as supplementary to treating it as the spine around which theory is organised; that reflective supervision must be recognised and taught as a core pedagogical technology, not a postgraduate add-on; and that the knowledge generated in LMIC practice systems constitutes a contribution to the global GMH pedagogical evidence base, not a local exception to it.
Keywords: global mental health; pedagogy; experiential learning; MHPSS; Pakistan; competency development; community psychology; decolonial training; peer support; child protection.
Introduction: The Mismatch at the Heart of GMH Training
There is something uncomfortable about the current moment in global mental health education. The field has produced increasingly thoughtful frameworks for the competencies that practitioners need, from working ethically across power differentials, navigate cultural humility, think in systems, hold complexity, sustain themselves under pressure (Kohrt et al., 2016; Karadzhov et al., 2024). And yet the dominant method for developing these competencies is limited to a classroom, a workshop, or a short course, or a didactic lecture; modes of instruction that the pedagogical literature has repeatedly shown to be insufficient for developing the kinds of relational and adapted competencies that GMH practice demands (McKinnon et al., 2016).
Karadzhov (2025) has framed this gap precisely. Writing in this journal, he calls for GMH education to move towards competency-based, experiential, and interdisciplinary frameworks, advocating specifically for service learning, simulation-based learning, problem-based learning, and the cultivation of communities of practice. The editorial is important and timely. What it does not yet do, as Karadzhov himself acknowledges by issuing the call for papers, is show what those approaches look like when they are built from the ground up in a resource-constrained, high-need, post-conflict, climate-affected setting, by practitioners who had no choice but to make the learning work inside the system.
This is what this paper tries to address. Over roughly a decade of MHPSS work in Pakistan, spanning government partnerships in Khyber Pakhtunkhwa, UN agency collaboration with WHO, UNFPA, IMC, and UNICEF, frontline programme supervision, disaster management training, and academic teaching, the author designed, tested, and refined approaches to professional formation that did not start from curriculum and work towards practice. They started from practice and built the learning structures around it. Every day at work was used as evidence to generate learning structures. These structures were then applied and tested for efficacy. The result was not always tidy. It produced practitioners who could sit with a child protection case they had never encountered before, ask the community what they knew, reflect with their supervisor on what they meant, and go back the next week with a refined approach. The kind of practitioner is exactly what Karadzhov (2025) describes when he calls for ‘agile, resilient and ethically conscious professionals.’ This paper describes how you, in practice, get there.
This paper is structured as follows. Section 2 locates the argument of the GMH pedagogical literature and names the specific gap it addresses. Section 3 provides context for the Pakistan setting and the author’s position within it. Section 4 presents four cases, each examined through the lens of a named pedagogical mode. Section 5 synthesises these cases into the system-embedded pedagogy framework. Section 6 draws concrete implications for universities and academic institutions preparing GMH professionals. A brief reflexive note closes the paper.
What the GMH Pedagogical Literature Promises and Where It Falls Short
The argument for experiential learning in GMH training is not new. Kolb’s (1984) foundational model, experience, reflection, conceptualisation, and renewed action, has been cited in health professional education for four decades, and the evidence base for service learning as a mechanism for developing structural competency, cultural humility, and civic awareness is now substantial (McKinnon et al., 2016; Ruiz et al., 2024). Karadzhov (2025) synthesises this literature fluently, and his editorial represents the most coherent case for transforming GMH training curricula.
The gap in this literature, and its is a significant one, is the near-total absence of accounts from practitioners in LMICs who have learnt and then built these pedagogical modes into functioning systems, rather than designing them as educational interventions sitting alongside those systems. The experiential learning literature is dominated by accounts of students from high-income institutions placed in global health settings for defined periods: they learn, they reflect, they return home (Hansoti et al., 2021). What is far less documented is what happens when the practitioner never leaves, when they are simultaneously the system builder, the supervisor, the trainer, and the learner, and when the communities they work with are not field sites for external education but sources of knowledge that the training must be designed to incorporate.
There is also a specific gap around supervision as pedagogy. The clinical supervision literature is clear that workshop training alone does not produce sustained skill acquisition (Beidas & Kendall, 2010), and the reflective supervision, structured, developmental, relationship-based, is one of the most reflective mechanisms for building competency in practising mental health workers (Locke et al., 2018). Yet supervision skills are rarely taught explicitly in GMH pre-service programmes and left out of most clinical programs. They are assumed to develop with experience or left to postgraduate continuing professional development. Given that the author’s experience in Pakistan suggests structured reflective supervision was the single most powerful vehicle for practitioner development across every programme examined, this neglect in the GMH curriculum seems worth naming directly.
Context and Positionality
Pakistan is not an obvious place to look for pedagogical innovation. It is a country with one of the largest mental health treatment gaps in the world, fewer than 500 psychiatrists for a population of over 200 million, a mental health budget that has historically represented less than 0.5% of total health expenditure, and no comprehensive mental health legislation until very recently (WHO, 2024). It is also a country that has been managing the mental health consequences of chronic conflict, recurrent catastrophic flooding, mass internal displacement, and a global pandemic, largely without the professional workforce infrastructure that GMH frameworks take as a baseline assumption.
These constraints did not produce deficits in MHPSS practice. They produced ingenuity. When there are not enough psychologists to provide specialist mental health service, you train associated service providers (health, social services, education). When communities are unreachable by fixed-site services, you put the services on wheels. When adolescents face mental health challenges in schools, you train their peers. Each of these adaptations is, in the language of the GMH pedagogical literature, an example of task-sharing, service learning, and peer-led education. In Pakistan, they were simply what work required.
The author developed her understanding of the core concepts of GMH, practising them on the ground, while implementing these interventions and acknowledges that the most useful lessons were the ones that were experientially learnt in the field with some excellent supervisors, through extensive reading and from the communities.
The author’s positioning at government, developmental, and academic institutes in Pakistan, GMH Fellowship with the Duke-NUS Medical School Singapore and in affiliation with the UK academic institutes is directly relevant to the argument of this paper. It means the author has practised and taught GMH from different sides of the epistemic divide that the paper is attempting to describe, and has experienced directly the way in which Global North academic frameworks can simultaneously provide intellectual scaffolding and obscure the validity of practice knowledge generated in the South. It also means this paper is written with a clear sense of audience: the UK-based, European-based, or Global South-based academic who is designing GMH curricula, reviewing placement frameworks, or supervising students who will work in LMIC settings. This paper is written for you, with evidence from the field, and with genuine affection for the difficulty of your task.
Four Cases, Four Pedagogical Modes
Each of the following cases is described as a service model and then examined explicitly as a pedagogical one. The aim is to highlight the learning architecture embedded in each programme, and the architecture that was built, in most cases, not out of educational theory but out of practical necessity.
Service Learning and Experiential Education: The CP Van as a Mobile Learning Ecosystem
Child Protection Vans are mobile outreach units that bring child protection and MHPSS services directly into communities, schools, informal settlements, and underserved districts that fixed-site provision cannot reach. For the worker who staffed them, each deployment was an encounter with a different community context, a different set of power dynamics, a different local vocabulary for distress. The variability was not managed or smoothed; it was the curriculum. McKinnon et al. (2016) define global service learning as a community-driven experience employing structured, critically reflective practice. In the CP Van model, this was not a supplement to academic coursework; it was the entire professional environment. Workers returned from deployments to structured group reflection sessions in which cases were discussed, assumptions tested, and frameworks revised. This is Kolb’s (1984) experiential cycle in its fullest form: concrete experience in genuinely varied contexts, structured reflection, collaborative conceptualisation, renewed action. The critical design principle, one that the service-learning literature rarely states explicitly, is that the learning environment and the practice environment must be the same environment. Placing students in communities to practice what they have already been taught reproduces the banking model of education in the field context (Freire, 2000). The CP Van placed workers in communities to learn from them, with theory introduced to make sense of what the community had already demonstrated.
Reflective Supervision as Formative Pedagogy: The District Child Protection Units
Workers in Khyber Pakhtunkhwa’s district Child Protection Units entered the system with pre-service training that covered legal frameworks, referral pathways, child development, and indicators of abuse, a structured case management package. Honestly, that training did not produce the practitioners the work required. What produced them was supervision. Weekly group-based sessions were structured around case discussion, a CPO bringing a case they were finding difficult, a family resisting intervention, a presentation that fit no existing framework. The supervisor’s role was not to provide the correct answer but to ask the questions that would eventually enable the worker to generate it themselves: What do you think the family is protecting? What does the community understand as harm here? What is the evidence that your approach is working? This is Schon’s (1983) reflection-in-action and reflection-on-action, not as aspiration but as the weekly lived experience of the workforce. The evidence base is consistent: workshop training does not produce sustained skill acquisition; structured reflective supervision does (Falender & Shafranske, 2014). The DCPU model demonstrated this across many cases over the last three years. The implication for academia could not be more direct: teaching practitioners to give and receive developmental supervision should be a core pre-service competency, not an afterthought.
Peer-Led and Collaborative Learning: I Support My Friends
The I Support My Friends programme trained adolescents to recognise distress in their peers, offer structured first-level support, and navigate referral pathways. Its design process revealed immediately that these young people held knowledge no external curriculum possessed: the social architecture of their peer groups, the routes through which distress was communicated and concealed, the specific idioms through which mental health could be raised without triggering shame. This was not supplementary information; it was the curriculum’s most critical input. Karadzhov (2025) advocates for collaborative learning as the lifeblood of GMH; I Support My Friends extends that logic to its most radical point, positioning young people themselves as primary knowledge holders and learning mediators. The pedagogical literature on peer learning is clear that peer-led approaches produce educational and relational benefits that expert-led approaches cannot replicate, including deeper knowledge and a stronger sense of agency (Burgess et al., 2020). Evidence from LMICs confirms that peer-mediated support consistently outperforms adult-delivered provision in reaching adolescents outside formal systems (Barry et al., 2013). But the programme’s most important pedagogical lesson was subtler: when community knowledge is treated as constitutive rather than supplementary, built into the curriculum rather than worked around, the boundary between teacher and learner becomes genuinely porous. That is not a nice aspiration. It is a design principle.
Embodied and Contextual Learning: Sports-Based Mental Health
Sports-based mental health programming operated on a straightforward premise: in communities where mental health remains deeply stigmatised, sports create entry conditions that clinical settings cannot. Facilitators, coaches, youth workers, and community animators trained in basic psychosocial skills encountered emotional dysregulation, social withdrawal, and trauma responses in the context of play, long before they might encounter these presentations in a formal service setting. The observational and relational competencies they developed were context-specific in ways no classroom replicates. This is what Karadzhov (2025) means by authentic learning: not only using real cases instead of fictional ones but encountering the full relational texture of the practice environment under appropriate supervision. Evidence from comparable LMIC programmes confirms that sports-based approaches produce meaningful improvements in adolescent wellbeing when community ownership, sustained supervision, and local norm sensitivity are present (Kidd et al., 2023). The academic implication is underutilised: observation placements in non-clinical community settings, sports programmes, youth clubs, and faith communities should be standard in GMH pre-service training, not because they replace clinical competency but because they build the foundational observational literacy that clinical training too often assumes practitioners already have.
System-Based Pedagogy: A Framework
Across the four cases, a coherent set of principles emerges that the author terms system-embedded pedagogy. This is not a new theory of learning. It is a synthesis of what the cases demonstrate about how effective professional formation in MHPSS happens when educational design takes the system as its starting point rather than the curriculum.
The first principle is that learning must be embedded in functioning service delivery, not appended to it. Every case above produced its most significant practitioner development through structured engagement with real service challenges, not through pre-service instruction. Training budgets and operational budgets must be integrated; supervision must be resourced as a continuous feature of the service. A training model that ends when the contract ends has not produced a learning environment. It has produced a visit.
The second principle is that knowledge must flow horizontally as well as vertically. In every case, the most contextually valid knowledge came from frontline workers, community members, and, most strikingly, from the young people in I Support My Friends. Professional formation that treats this knowledge as supplementary will produce practitioners who are formally competent in frameworks that communities experience as foreign. Formation that treats it as constitutive, building it into supervision structures, curriculum design, and competency assessment, produces practitioners who can actually do the work. This is not a romantic claim about community wisdom. It is an empirical one: workers who knew what the community knew were more effective than those who did not.
The third principle is that communities must function as co-educators, not service recipients. This is the most politically demanding of the three. It requires institutions, universities, international organisations, and government agencies to accept that the validity of the knowledge shaping professional training cannot be determined by those institutions alone. It must be negotiated, continuously, with the communities for whom training is ultimately designed. The CPC members who co-designed child protection protocols were not being consulted as stakeholders. They were functioning as curriculum designers. That distinction is the heart of the framework.
These three principles do not replace the approaches Karadzhov (2025) advocates. They provide the system context in which those approaches can genuinely work. Service learning that is not embedded in functioning systems remains extractive. Supervision that is not structured as developmental learning remains evaluative. Peer learning that does not incorporate community knowledge stays inward-facing. System-embedded pedagogy is the condition of possibility for the pedagogical transformation the GMH field needs.
What Academic Institutes Can DO Differently
This section makes no apology for being prescriptive. It is addressed to the academic who is designing a GMH module, reviewing a placement framework, or supervising students who will work in settings like the ones described in this paper. The question it tries to answer is not 'what should GMH training aspire to?' The field has enough aspiration. The question is: given what the Pakistan experience demonstrates, what specifically should change?
Redesign Placement as the Curricular Spine, Not a Peripheral Requirement
Almost every GMH programme includes fieldwork. In most cases, it is a supplementary requirement, assessed separately, marginal to the intellectual life of the course. System-embedded pedagogy inverts this. Field placement, genuinely embedded in a functioning service, with real supervisory relationships and real accountability to community outcomes, should be the organising spine of GMH education, with academic instruction providing conceptual scaffolding for what students encounter in the field. This requires sustained investment in placement partnerships: not arrangements in which a university deposits students in an organisation for defined hours, but collaborative relationships in which field supervisors are recognised as academic contributors, communities have meaningful input into learning objectives, and knowledge generated in the field actively reshapes the classroom curriculum. This is service learning in the fullest sense, McKinnon et al. (2016) describe. It is achievable. It demands that academic institutions value forms of knowledge production not always legible to research assessment frameworks, and that is an institutional challenge worth naming honestly.
Teach Supervision as a Core Pre-Service Competency
If supervision is the primary mechanism through which competency is built in practice, and the evidence suggests it is (Falender & Shafranske, 2014; Locke et al., 2018), then teaching practitioners to give and receive it should begin before they enter the field. How to bring genuine uncertainty to a reflective discussion, how to use the supervisory relationship as a site of learning rather than performance, how to facilitate case discussion that builds critical thinking rather than protocol compliance, these are teachable skills. They are currently treated as things that experienced practitioners eventually develop. The DCPU and helpline models demonstrate that good supervision structure, not seniority alone, produces competent workers. WHO and UNICEF's EQUIP initiative has developed competency-based frameworks for supervision training that academic programmes could build on (Kohrt et al., 2018). The field has the tools. It needs to make supervision literacy a graduation requirement.
Redesign North-South Partnerships Around Epistemic Reciprocity
North-South GMH partnership typically follows a similar pattern: Global North institutions provide theoretical frameworks, credentialing, and publication infrastructure; Global South institutes provide field access, participants, and data. Even when unintentional, this reproduces the epistemic hierarchy that the decolonial literature has long critiqued (Eaton, 2019). This paper offers something different: a body of practice knowledge about experiential learning, reflective supervision, community coproduction, and interprofessional education that Global North curricula need, not as cultural illustration but as a substantive input. Universities genuinely committed to decolonising their GMH programmes must redesign partnerships so that Southern practice knowledge shapes Norther curricula, not the other way around. That means inviting LMIC practitioners as co-designers of training content, assigning LMIC-authored case studies some intellectual weight and building institutional structures that make this kind of knowledge exchange sustainable beyond individual relationships.
Reflexive Note
This paper is a reflective practitioner case study. Its claim rests on one practitioner’s direct experience across a specific national context. The absence of systematic evaluation data on learning outcomes or competency trajectories is a genuine limitation, acknowledged rather than obscured. The cases are offered as evidence for a direction — one that researchers better positioned for longitudinal evaluation should develop further. The author's dual role as programme designer and analyst creates the closeness that makes certain things visible and others harder to see. The decolonial framing should not be read as a rejection of international GMH frameworks: the IASC guidelines, WHO PFA materials, and the EQUIP platform all contributed to the work described. The argument is that these frameworks are insufficient without the processes of community co-production and reflective practice that system-embedded pedagogy requires, and that the knowledge generated through those processes belongs in the international evidence base, not merely in footnotes about local adaptation.
Conclusion
Karadzhov (2025) ends his editorial with a call for papers exploring contextualised, collaborative, and transformative practices in GMH education. This paper is an answer to that call, not from a researcher who has studied these approaches, but from a practitioner who has spent a decade building them inside a system that could not afford to wait for pedagogical literature to catch up.
The CP Van is experiential learning. The DCPU supervision model is reflective supervision as formative pedagogy. I Support My Friends is peer-led collaborative learning. The sports-based MHPSS model is embodied in an authentic professional formation. These are not analogies to pedagogical approaches, rather they are those approaches, built in a context that required them to work.
Pakistan’s MHPSS experience offers the GMH pedagogical field a demonstration of what Karadzhov’s (2025) aspirations look like when they are operationalised under the hardest possible conditions. The field should be paying attention, not because we have all the answers, but because we are answering all the right questions.
Ethical Statement: This paper is a reflective practitioner case study based on professional experience in programme design, implementation, and supervision. No primary data were collected from human participants. All programmatic activities were conducted within the ethical frameworks of the implementing organisations, including UNICEF Pakistan and the Government of Khyber Pakhtunkhwa, and in accordance with the professional ethical guidelines of the Pakistan Psychological Association and the IASC ethical principles for MHPSS in humanitarian settings (IASC, 2007). Confidentiality of service users, community members, and frontline workers has been maintained throughout; no identifying information has been disclosed.
Data Availability Statement: No original datasets were generated or analysed for this manuscript. Programme documentation and institutional reports referenced are held by implementing organisations, including UNICEF Pakistan and the Government of Khyber Pakhtunkhwa, subject to institutional data governance policies.
Funding: No specific funding was received for the preparation of this manuscript. The programmatic work described was funded through UNICEF Pakistan and the Government of Khyber Pakhtunkhwa. These bodies had no role in the design, writing, or decision to publish this paper.
Competing Interests: The author declares no competing interests.
Use of AI Technologies: The author used Consensus to identify articles for the literature review. Furthermore, the author used Claude (Anthropic, claude-sonnet-4-6) to structure the first draft based on a detailed written brief specifying the programmes, argument, references, theoretical framework, and submission guidelines. The author reviewed, substantially revised, and takes full intellectual and academic responsibility for the final text. Conceptualisation, argument, and all claims are the author’s own.
Acknowledgement: The author is grateful to the project teams, community protection committee members, and, most of all, the children and young people of Khyber Pakhtunkhwa whose work and wisdom are the empirical foundation of everything argued here. Thanks are due to colleagues at UNICEF Pakistan and the Government of Khyber Pakhtunkhwa for the institutional trust that made sustained, systemic work possible. The University of Glasgow affiliate position offered the comparative perspective through which the value of the Pakistan experience became fully visible. This paper is dedicated to every MHPSS practitioner who figured something important out in the field and had no one to tell.
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