A recount of major challenges and lessons from Pakistan’s Covid experience
he Covid-19 pandemic brought a truly unprecedented challenge to the world and its governments. Pakistan was no exception. In hindsight, it appears that on a number of parameters, Pakistan fared reasonably well in tackling the pandemic. To analyse and curate some of what went right, here are some of the salient features that defined Pakistan’s Covid-19 response.
First, and foremost, was the underlying vision and philosophy enunciated by the political leadership, in particular the prime minister. As the pandemic evolved, there was predictable fear and panic. The predictions and estimates coming out from some leading universities and research centres painted a doomsday scenario, especially in countries with weak health systems. Projections of tens of thousands of deaths a day were put forth. China, with its somewhat unique governmental and societal structure, had deployed a “lockdown” – strict in its definition and implementation – but with extensive governmental and societal support to those under such areas of restricted mobility. In this backdrop, it was but natural that some parts of Pakistani society clamoured for “lock down now”. Often, the demand came from the more privileged and educated segments of society, both because of greater connectivity with the world and the assumed ability to weather such shutdowns. Concurrently, another part of society exhibited disbelief in the pandemic’s potential for disaster. In this scenario, the fundamental directive to those managing the pandemic was: do everything reasonable to staunch the pandemic and save lives, but without shutting down life for the ordinary Pakistani citizen. Lives and life must go on. This was the underpinning of Pakistan’s strategy to combat Covid-19.
Second, implementing a vision presents major challenges in large countries with devolved federal structures, especially devolved health delivery and public health systems. Many countries, including the US, India and Brazil, struggled to formulate coherent national responses. Pakistan, a large, populous and diverse country with a near-total devolution of health care delivery since the 18th Amendment, faced a similar challenge. In early 2020, the Ministry of Health Services, Regulation and Coordination did not have the kind of bandwidth needed to tackle a pandemic of this scale. Timely efforts were made by Dr Zafar Mirza, the special assistant to the PM, starting in mid-January 2020 to form a working group to bring expertise and coordination to the table but the formation of the National Command and Operation Centre became the most important pivot to swing the national vision into action. The NCOC, chaired by the minister for planning, had at its disposal a very capable and committed contingent of the Pakistan Armed Forces. Every single day its senior officers ensured coordination, follow up, implementation and evaluation of the data coming in. It was able to leverage professional and technical strengths from various ministries and to ensure that the provincial leaderships were on board for key decisions. This enabled data driven consensus-based decisions. The bureaucratic machinery demonstrated stellar capabilities in implementing and detailing the plans. Many initiatives were taken locally and made their way up through the NCOC for sharing elsewhere.
A number of critical operational interventions had to be sorted out. Managing the pandemic required a reliable count of cases. Early on there were only around four laboratories doing the PCR tests for the coronavirus. The National Institute of Health not only helped bring this number up to 173 with a daily capacity of 100,000 tests, but also had a key role in quality assurance. Another challenge was the flow of information from the provinces to the NCOC, and of plans, policies and directives in the other direction. The existing database that collects data on poliovirus cases was marshalled into use for the flow of information about Covid-19 cases. Crucial roles were played in this regard by the polio programme, the NITB, the Digital Pakistan and other information system entities. Several different data modellers and epidemiologists helped create reliable forecasts for cases and healthcare requirements. Accurate dashboards for timely availability of capacity and its fill up across 4,000 health establishments was made possible. This not only helped decision makers in the NCOC, but also provided guidance to the citizens to find available hospital beds during peaks of various waves through a mobile phone application.
Data regarding patients and their contact tracing helped generate “heat maps” to implement targeted (or ‘smart’) lockdowns that helped focus the intervention where most needed rather have large shutdowns that would have had societal, economic and health impacts on the country. Such data was also pivotal in decision making for the closure or opening of various sectors, such as education and the hospitality industry.
One of the challenges throughout the pandemic was maintaining availability of a range of supplies and equipment. The NDMA ensured that masks, face shields, gowns and other medical equipment were procured and supplied to health facilities across the country. Continued availability of testing kits, vaccines, ventilators and oxygen was ensured by accurate forecasting and timely procurement in difficult global market conditions.
While efforts to mitigate the pandemic were important, it was clear that a ramp up of facilities including oxygenated beds, ventilators and critical care beds would be required during epidemic surges. Over 7,000 such beds were added into the system and helped in assuring availability during times of high demand. An untold story is the increase in the oxygen generating capacity that went up from under 500 metric tonnes per day to over 800 metric tonnes per day for the country within a few months. Without this 60 percent increase in the summer of 2020, there would have been shortages during subsequent pandemic waves. Not only was the raw supply of oxygen increased, but the supply chain was bolstered to ensure that oxygen was available across the full length and breadth of Pakistan.
Pakistan’s Covid vaccination drive surprised many naysayers despite initial hiccups due to serious supply chain shortages and export bans by major vaccine manufacturing countries. By September 2022, around 90 percent of the eligible population was fully vaccinated. This was made possible through agile sourcing, purchase and later, supply via the COVAX arrangements, ramp up of the vaccine distribution and cold chain and creation of mobile vaccination centres. Accurate and reliable documentation was enabled by having a verifiable national database of inoculated individuals built upon the NADRA database. The peak vaccination period saw nearly 2.3 million doses administered in a single day. Perhaps no public health intervention in the country has touched virtually every citizen in such a short time with a documented equitable rollout.
Interventions like cash distribution to needy families via the Ehsaas Programme and breaks in the utility bills to small enterprises also helped to cushion the fallout from the pandemic and its restrictions. Maintaining connectivity with the world while ensuring safety of passengers required a Herculean effort by authorities across airports and border crossings.
The media played a crucial role in informing the public of the threats and the need to comply with safety measures like use of masks and other restrictions. Countering misinformation is critical; over a hundred Covid-related guidance and policy documents were put forth by the ministry with the help of top experts. Use of caller ringtones to inform the public of key pandemic-related information became a powerful communication tool. Engaging with senior religious leaders in the country helped the buy-in and support enabling adoption of social distancing practices in mosques and at religious events and gatherings.
Decisions and recommendations of the NCOC also received endorsements from the superior judiciary to enable smooth implementation of pandemic restrictions.
The net result of these efforts was a mortality number that was a fraction of what many had forecast; economic resilience during the pandemic as reported by the Economist in January 2022 in its Economic Normalcy Index; high vaccination rates and the fact that the health system was able to cope with the surges in all waves. Despite coming close capacity, the capacity was never fully tripped over. This is also a testament to the bravery and selflessness of healthcare workers who put their work commitments over and above their own safety.
Pakistan deployed an ‘all of the nation’ approach in a true sense. Going forward, it will be important to institutionalise these lessons. To ensure this, the government initiated and received support in the legislature for an act to reform and upgrade the NIH and to create several new entities in it, including a Centre for Disease Control, so that future pandemics can be handled better.
The writer is a former special assistant to the prime minister on national health services