Cost-utility analysis of a telephonic counseling intervention for depression and anxiety: A provider-perspective evaluation of the Taskeen Health Initiative in Pakistan, 2023

Abstract

Depression and anxiety impose a substantial burden in Pakistan. Workforce shortages, concentration of services in urban tertiary settings, low public financing and prevalent stigma as signifcant barriers to mental healthcare. Telephonic counseling has emerged as a scalable delivery model, but rigorous economic evidence for such interventions in Pakistan remains limited. This study evaluates the cost-utlity of a nationwide telephonic counseling helpline delivered by the Taskeen health Initiative for the year 2023. A provider-persepctive analysis was conducted using observational, retrospective, pre-post design of the 2023 program year, with a counterfactual no-intervention scenario as comparator. The complete program population of service users (n=4261) formed the cost denominator; health outcomes were assessed in a subset cohort (n=651) with both pre- and post-intervention PHQ-9 and GAD-7 assessments. Years lived with disability (YLDs) averted per participant served as the primary health outcome, calculated using the disability weights from the Global Burden of Disease 2019 study and multiplicative complement rule. Incremental cost-effectiveness ratio (ICER) was assessed against Pakistan’s 2023 GDP per capita (USD 1,396) as the willingness-to pay (WTP) threshold. Robustness was evaluated through one-way deterministic sensitivity analysis, a scenario analysis imputing outcomes for psychiatrically referred participants using literative-derived effect sizes, and a probabilistic sensitivity analysis (PSA) of 10,000 Monte Carlo iterations. The intervention averted 0.197 YLDs per participant, yielding a base case ICER of USD 117.67 at unit cost of USD 23.15 per participant. ICER was 8% of the WTP and below the most conservative opportunity-cost threshold of 0.2xGDP per capita (USD 279). The cost-effectiveness conclusion was robust across all sensitivity analyses: the deterministic ICER ranged from USD 58.84 to USD 235.35, the scenario analysis produced ICERs of USD 119.91–120.59, and across 10,000 PSA iterations the mean ICER was USD 136.43 (95% credible interval: 58.18–255.86). All PSA iterations fell below the 1× GDP per capita threshold, indicating 100% probability of cost-effectiveness, and 98.7% remained cost-effective even at the 0.2× GDP per capita threshold. Telephonic counseling delivered by the Taskeen Health Initiative is highly cost-effective for reducing depression and anxiety symptoms in Pakistan, with a conclusion robust to deterministic, scenario-based, and probabilistic uncertainty. To our knowledge, this is the first published provider-perspective cost-utility analysis of a national telephonic mental health intervention in Pakistan.