Non-communicable diseases (NCDs) are rapidly increasing and are now responsible for 64% of deaths and disabilities globally. In Pakistan and Afghanistan, they account for almost a million deaths every year.
There is an urgent need for new interventions that are effective and can be delivered at scale in low-resource, conflict-affected settings. The five-year £7.6m Centre provides new opportunities to develop, test and embed evidence-based treatments that address NCDs.
The Centre will deliver on four research themes, based on local needs, knowledge gaps, value-of-information analysis, and stakeholder-identified priorities.
For each theme, established consensus development methods will be used to select candidate interventions.
Population-level interventions
The behavioural risk factors posed by noncommunicable diseases pose substantial challenges in Pakistan.
Afghanistan is increasingly adding noncommunicable disease risk factors to its ongoing burden of communicable diseases.
The ongoing humanitarian crisis situation calls for more rather than less action for health, including for noncommunicable diseases, which typically do not receive the attention they deserve in such circumstances, particularly for preventive noncommunicable diseases policies.
Aims:
- Model potential policies that governments may consider implementing
- Produce evidence that can be used by governments and international agencies to inform population-level policies on noncommunicable diseases
- Produce evidence on the socioeconomic correlates, determinants, consequences of NCD behavioural risk factors
- Evaluate existing population-level policies on noncommunicable disease
Resources
Read more: Country Cooperation Strategy for WHO and Pakistan 2020–2025.
Addressing the mental health treatment gapCommon mental disorders (depression and anxiety) in Afghanistan are responsible for 0.7m disability-adjusted life years lost. In Pakistan, common mental disorders are responsible for 3.1m disability-adjusted life years lost. Yet more than 90% of cases go untreated.
The aim of this Research Theme is to focus on the prevalence of common mental disorders (CMDs) in post-conflict settings and chronic physical disease populations, where implementation of effective interventions, delivered by non-specialist workers, has huge potential to alleviate distress, improve health and save costs.
Why here? Why now?
The rising burden of multimorbid depression and noncommunicable diseases is a global challenge, largely neglected by healthcare services, particularly in Low- and Middle-income Countries. Coexistence of depression and chronic physical diseases is highly prevalent and worsens outcomes for both the mental and physical disorder, affecting both quality of life and finances as healthcare costs increase.
Tackling depression alongside chronic diseases is therefore a high priority, made particularly urgent by the rising burden of mental disorders associated with the Covid-19 pandemic, and the unprecedented scale of floods in Pakistan, leading to loss of homes and livelihoods and multiple health problems. People with noncommunicable diseases are 2-3 more times likely to have depression. The coexistence of noncommunicable diseases and common mental disorders contributes significantly to global deaths. However, in Pakistan (as around the rest of the world!), mental health expertise and resources to respond to this high need are limited.
So innovative evidence-based solutions are urgently needed to address the widening mental health treatment gap.
The two strands of the Mental Health Research Theme:
SPiRiT-DThe SPiRiT-D arm of the Centre for IMPACT aims to evaluate the effectiveness, cost-effectiveness, and implementation of the Collaborative Care model for treating depression in primary care clinics in Pakistan, where access to mental health services is limited.
Working with the SINA healthcare network in Karachi, the project has adapted the model to the local context, and is currently testing it through a hybrid type-II effectiveness implementation cluster randomised controlled trial.
Vitally, the project will explore strategies for its long-term scale-up and sustainability.
The trial is being conducted in 24 SINA primary care clinics and has achieved its recruitment target. The 725 participants recruited are being followed up at 3, 6 and 12 months follow-up to assess effectiveness outcomes (such as depression severity, caseness), and implemention outcomes (such as treatment reach, implementation).
Collaborative care is a model of care delivery that provides patient-centred, cost-efficient care without relying on having many mental health specialists, and has been shown to be effective for treating depression in patients with noncommunicable diseases.
Principles of Collaborative Care
- Care is provided by a Team based in a health service setting.
- The Team systematically identifies people who have depression, through routine screening with a simple questionnaire Patient Health Questionnaire-9 (PHQ-9).
- The Team provides treatments for depression (medicines and/or brief psychological treatment) according to a protocol.
- The Team monitors response to treatment using a treatment tracking tool.
- Team members are non-specialists who are trained to screen and treat depression. We train them in Behavioural Activation therapy because it works for depression, and it is relatively easy to learn.
- Non-specialists are supervised remotely by a mental health specialist only for the few cases where there are complications.
Implementation of collaborative care for depression in physical health programmes is widely recommended.
PM+The PM+ project is an implementation evaluation study spanning Pakistan and Afghanistan, designed to scale up the World Health Organization’s Problem Management Plus (PM+) intervention. By leveraging a task-shifting model—delegating key psychological support strategies to trained community members—the project builds local capacity to make mental health care accessible while reducing the structural burden on specialized healthcare systems.
Country-Specific Strategies
Pakistan
The project aims to train 300 mental health specialists across 6 regions and at least 30 mental health institutes. Operating as master trainers, these specialists will cascade their knowledge to frontline workers, establishing a robust framework to roll out PM+ at scale.
Afghanistan
Capacity is being built directly within the community layout. The project is training 717 Community Health Workers (CHWs) and 75 Community Health Supervisors (CHSs) across 5 provinces to deliver essential, frontline psychological support.
Preventing diabetesPakistan ranks 4th in the world for the number of people with type-2 diabetes (diabetes) in 2019 (19m), 2030 (26m) and 2045 (36m).
The Centre will deliver a set of studies involving patients, families and communities in diabetes prevention.
In Pakistan:
- Assess (cost-)effectiveness of a community mobilisation intervention in preventing diabetes
- Assess feasibility of a family-based intervention to prevent and manage diabetes
In Afghanistan and in Karachi, Pakistan (urban site), we will assess the feasibility of the above approaches.
Reducing cardiovascular disease riskA steep rise in CVD burden in LMICs calls for an urgent need for strengthening health systems and multi-sectoral collaborations.
Building on our previous work on hypertension, and medications access, community-based CVD cohorts, and school- based approaches for childhood obesity, in Pakistan, we aim to:
- Study the implementation of an evidence-based community-based hypertension control intervention
- Co-create and evaluate the (cost-)effectiveness of a workplace-based programme for reducing CVD risk
- Assess the feasibility of school-based interventions for addressing childhood obesity
The behavioural risk factors posed by noncommunicable diseases pose substantial challenges in Pakistan.
Afghanistan is increasingly adding noncommunicable disease risk factors to its ongoing burden of communicable diseases.
The ongoing humanitarian crisis situation calls for more rather than less action for health, including for noncommunicable diseases, which typically do not receive the attention they deserve in such circumstances, particularly for preventive noncommunicable diseases policies.
Aims:
- Model potential policies that governments may consider implementing
- Produce evidence that can be used by governments and international agencies to inform population-level policies on noncommunicable diseases
- Produce evidence on the socioeconomic correlates, determinants, consequences of NCD behavioural risk factors
- Evaluate existing population-level policies on noncommunicable disease
Resources
Read more: Country Cooperation Strategy for WHO and Pakistan 2020–2025.
Common mental disorders (depression and anxiety) in Afghanistan are responsible for 0.7m disability-adjusted life years lost. In Pakistan, common mental disorders are responsible for 3.1m disability-adjusted life years lost. Yet more than 90% of cases go untreated.
The aim of this Research Theme is to focus on the prevalence of common mental disorders (CMDs) in post-conflict settings and chronic physical disease populations, where implementation of effective interventions, delivered by non-specialist workers, has huge potential to alleviate distress, improve health and save costs.
Why here? Why now?
The rising burden of multimorbid depression and noncommunicable diseases is a global challenge, largely neglected by healthcare services, particularly in Low- and Middle-income Countries. Coexistence of depression and chronic physical diseases is highly prevalent and worsens outcomes for both the mental and physical disorder, affecting both quality of life and finances as healthcare costs increase.
Tackling depression alongside chronic diseases is therefore a high priority, made particularly urgent by the rising burden of mental disorders associated with the Covid-19 pandemic, and the unprecedented scale of floods in Pakistan, leading to loss of homes and livelihoods and multiple health problems. People with noncommunicable diseases are 2-3 more times likely to have depression. The coexistence of noncommunicable diseases and common mental disorders contributes significantly to global deaths. However, in Pakistan (as around the rest of the world!), mental health expertise and resources to respond to this high need are limited.
So innovative evidence-based solutions are urgently needed to address the widening mental health treatment gap.
The two strands of the Mental Health Research Theme:
The SPiRiT-D arm of the Centre for IMPACT aims to evaluate the effectiveness, cost-effectiveness, and implementation of the Collaborative Care model for treating depression in primary care clinics in Pakistan, where access to mental health services is limited. Working with the SINA healthcare network in Karachi, the project has adapted the model to the local context, and is currently testing it through a hybrid type-II effectiveness implementation cluster randomised controlled trial. Vitally, the project will explore strategies for its long-term scale-up and sustainability. The trial is being conducted in 24 SINA primary care clinics and has achieved its recruitment target. The 725 participants recruited are being followed up at 3, 6 and 12 months follow-up to assess effectiveness outcomes (such as depression severity, caseness), and implemention outcomes (such as treatment reach, implementation). Collaborative care is a model of care delivery that provides patient-centred, cost-efficient care without relying on having many mental health specialists, and has been shown to be effective for treating depression in patients with noncommunicable diseases. Implementation of collaborative care for depression in physical health programmes is widely recommended.Principles of Collaborative Care
The PM+ project is an implementation evaluation study spanning Pakistan and Afghanistan, designed to scale up the World Health Organization’s Problem Management Plus (PM+) intervention. By leveraging a task-shifting model—delegating key psychological support strategies to trained community members—the project builds local capacity to make mental health care accessible while reducing the structural burden on specialized healthcare systems. The project aims to train 300 mental health specialists across 6 regions and at least 30 mental health institutes. Operating as master trainers, these specialists will cascade their knowledge to frontline workers, establishing a robust framework to roll out PM+ at scale. Capacity is being built directly within the community layout. The project is training 717 Community Health Workers (CHWs) and 75 Community Health Supervisors (CHSs) across 5 provinces to deliver essential, frontline psychological support. Country-Specific Strategies
Pakistan
Afghanistan
Pakistan ranks 4th in the world for the number of people with type-2 diabetes (diabetes) in 2019 (19m), 2030 (26m) and 2045 (36m).
The Centre will deliver a set of studies involving patients, families and communities in diabetes prevention.
In Pakistan:
- Assess (cost-)effectiveness of a community mobilisation intervention in preventing diabetes
- Assess feasibility of a family-based intervention to prevent and manage diabetes
In Afghanistan and in Karachi, Pakistan (urban site), we will assess the feasibility of the above approaches.
A steep rise in CVD burden in LMICs calls for an urgent need for strengthening health systems and multi-sectoral collaborations.
Building on our previous work on hypertension, and medications access, community-based CVD cohorts, and school- based approaches for childhood obesity, in Pakistan, we aim to:
- Study the implementation of an evidence-based community-based hypertension control intervention
- Co-create and evaluate the (cost-)effectiveness of a workplace-based programme for reducing CVD risk
- Assess the feasibility of school-based interventions for addressing childhood obesity
