CASE STUDY
Non-communicable diseases (NCDs) are among the top 10 causes of mortality and morbidity in Pakistan. The four non-communicable diseases (NCDs) causing the greatest morbidity and mortality are:

• cardiovascular diseases
• type-2 diabetes
• chronic respiratory diseases
• mental health.

The province of Punjab (in Pakistan) has a reasonable primary healthcare infrastructure in place, with about 140 hospitals; 295 rural health centres; and 2,500 basic health units. The private sector is also large, comprising both qualified and less-qualified service providers, catering for about 60% of curative consultations.
An integrated national action plan for prevention and control of NCDs was developed in 2003. Significant devolution of power has already taken place, with responsibility for health devolved to provincial and district governments. In mid 2013, the government of Pakistan signed the UN resolution for the global ‘Prevention and control of non-communicable diseases’.
The government of the Punjab Health Department has taken the lead in building the public sector capacity for addressing the challenge of NCD control in the province. Initially the provincial health department lacked:

• the organisational set-up with defined strategic priorities and allocated resources, and
• evidence-based and indigenous NCD care implementation products and modalities.

Organisational issues
A preliminary health facility survey was conducted on NCD case management arrangements and practices. The Director General Health Services (DGHS) Punjab, through a series of informal consultations, prepared a working paper on NCD control in Punjab and arranged for a provincial-level health services manager to be designated as a focal person for the control of NCD and mental health. This focal person then engaged multiple national and international partners who could contribute.
A Provincial Task Force for the Prevention and Control of NCDs and Mental Health, chaired by the DGHS, was formed with a broad representation of stakeholders. The Provincial Task Force, through extensive consultations, identified the priority NCD conditions for the province to focus on during the first few years. The conditions were: hypertension diabetes; chronic lung conditions; and mental health. The Task Force endorsed a technical assistance priority needs document which was used as a tool to share the programme needs and invite contribution from the potential partners for NCD control in the province.
Multiple collaborative projects were developed to mobilise resources for developing and evaluating the agreed priority NCD interventions (eg COMDIS-HSD, DFID, WDF, EU and Grand Challenge Canada grants). UNICEF has already offered technical assistance for developing a strategic plan for the control of NCDs in Punjab. In parallel, a proposal document is being developed (PC-1) to mobilise public resources for implementing NCD control in Punjab.
Evidence-based implementation products
A set of implementation products have been, or are being, developed, mainly by adapting the international technical guidelines and adding the operational strategies sensitive to the local context. This whole product development exercise has been done through a DGHS-led technical working group, under the guidance and endorsement of the provincial Task Force. The implementation products developed so far for an integrated NCD care delivery at primary health care level include:

• type-2 diabetes and hypertension care
• chronic lung health (asthma and COPD) care
• smoking cessation services.

The effectiveness of four NCD interventions is being evaluated mainly through cluster randomised controlled trials – embedded within early implementation – together with financial and social feasibility assessment, through costing and qualitative studies.
Challenges and lessons learned
Advocacy challenges – to bring NCDs up to par with other health priorities. In Punjab, this challenge has been addressed mainly by the DGHS informing and sensitising the decision-makers, supplemented by the external advocacy support of WHO, World Bank and others.
Lack of suitable international programme implementation products – addressed by nurturing product development partnerships with in-country partners.
Resource mobilisation by a newly-established setup – addressed through a two-pronged strategy:

• mobilising development partners for technical assistance; and
• engaging partners who can access national and international resources for NCD control.

Impact
The evaluation design includes defined outcome measures of feasibility and impact, for each respective intervention (available on request).
Next steps

1. Develop a provincial strategic plan and PC-1 for the ‘Prevention and control of non-communicable diseases in mental health’.
2. Continue to support the on-going development and research on diabetes/hypertension; chronic lung health; and child brain and maternal mental health interventions.
3. Expand the current partnership including assistance to other provinces and countries.

This case study was presented by our Pakistan partners ASD at the WHO Regional Office for the Eastern Mediterranean meeting on strengthening the integration and management of non-communicable diseases in primary health care, September 2014.
References

1. Siddiqi K, Khan A, Ahmad M, Dogar O, Kanaan M, Newell J N, Thomson H. (2013) Action to stop smoking in suspected tuberculosis (ASSIST) in Pakistan: a randomized controlled trial. Annals of Internal Medicine. doi.org/10.7326/0003-4819-158-9-201305070-00006
2. Khan A, Javed W, Ahmed M, Walley J, Khan H J. (2013) Delivering enhanced cardiovascular (hypertension) disease care through private health facilities in Pakistan. BioMed Central (BMC) Cardiovascular Disorders. doi.org/10.1186/1471-2261-13-76
3. Siddiqi K, Khan A, Ahmad M, Rehman S. (2010) An intervention to stop smoking among patients suspected of TB – evaluation of an integrated approach. BioMed Central (BMC) Public Health. doi.org/10.1186/1471-2458-10-160
4. Khan A, Khan H J. (2015) Strengthening the delivery of asthma and chronic obstructive pulmonary disease care at primary health care facilities: study design of a cluster randomized controlled trial in Pakistan. Global Health Action. doi.org/10.3402/gha.v8.28225