As things stand today, Pakistan seems to have successfully overcome Covid-19 through a united national effort. Though the threat of resurgence is looming, equally significant however is to reflect about what we should be learning from this experience and how we can improve our related policies, systems, institutions and health workforce.
While it is true that no country, including high income countries with advanced health systems, were prepared enough to deal with the devastation of Covid-19, yet each country, regardless of its income level has to have a bare-minimum health emergency preparedness and response system in place.
Having led the national effort in the first phase and being part of the core team after the establishment of the National Command and Operation Centre (NCOC) I have seen the situation from close enough to try to synthesise a few key learnings from this momentous experience. For want of space, a very succinct enumeration of ten major points is presented below, though each one of these requires a separate article.
One, we lacked a legal basis to declare a “national health emergency”. Such basis is still not available although a draft bill has already been prepared and was tabled before the cabinet which decided to forward it to the Council of Common Interests. This needs to be closely pursued before it fades away and we are struck with another national health emergency without knowing how to declare it.
Two, a global catastrophe of the Covid-19 scale requires a national and whole-of-government response. Horizontally working, we experienced great inter-sectoral collaboration between the civil and military establishments and various federal ministries: health; foreign office; interior; planning and development; industry; education; aviation; food security; religious affairs and others. But vertical collaboration between federal and provincial governments was a huge challenge. The 18th constitutional amendment in Pakistan has made this extremely difficult. This is linked with the first point above and needs to be effectively addressed without harming the spirit of devolution in health.
Three, the robust National Disaster Management Act (NDMA) 2010 has established an Authority and a powerful Commission chaired by the prime minister and having all chief ministers as its members. Why then did the NCOC have to be established from scratch? The NDM Commission has not met for more than two years! The NCOC worked extremely well but a more predictable institutional response needs to be sorted out for the future health emergencies.
Four, as signatory to the International Health Regulations (2005), Pakistan is yet to develop the required “core capacities” to prevent, detect and respond to health threats. The WHO sponsored the Joint External Evaluation in 2016 which looked in detail at 19 technical areas, including pandemic preparation. Comprehensive recommendations were made to improve national health emergency infrastructure but implementation is still awaited. Time to reread this evaluation and implement recommendations in light of the Covid-19 experience.
Five, an early measure in a pandemic is effective control of infected travellers from abroad. The Central Health Establishment (CHE) has a federal responsibility of screening and quarantining at 19 Points of Entry (airports etc) in the country. We swiftly, though with great difficulty, reinforced PoEs but also learnt about the limitations of the CHE as an organisation which now needs drastic reform to make it fit-for-purpose.
Six, disease surveillance data is the backbone of an outbreak response. In the absence of a national digital integrated health information system, we piggybacked Covid-19 surveillance on the polio program which has been extremely helpful. Also, study of incidence and distribution of diseases is the realm of epidemiologists which we don’t have enough of. Pakistan urgently needs a robust and real-time digital national disease surveillance system and a resourceful Rapid Response Team in each district led by a field-epidemiologist. There is some progress in this area which needs to be accelerated. Epidemiologists must be in the driving seat for disease control.
Seven, the NCOC has maintained a transparent approach and kept the nation informed at each step about the real disease situation. However, it took some effort to emphasize the significance of data transparency to some local administrators accustomed to under-report cases and deaths in order not to look bad. The worst thing any government can do during an epidemic is to hide data or to fudge figures. This mindset has to change.
Eight, there is an acute shortage of ICU beds and critical care specialists (less than 50!) in Pakistan. The NCOC supported provinces by contributing 2608 critical care beds with all auxiliaries by July 31, and we initiated a national training program in critical care. However, robust ramp-up planning in this regard is needed for the future.
Nine, tragically, we learnt how Covid-19 patients were stigmatised in some districts where even their homes were marked. At one stage a coercive provincial policy to pick all Covid-19 persons (even asymptomatic) from their homes scared-off people from testing and declaring their status. We need to work to change such perceptions.
Ten, we learnt about the power of proper risk communication and community engagement. Direct leadership interaction with people and full participation of the media including constant text-messages and message-tones to 167 million mobile phone users have contributed to a level of behaviour change. Managing disinformation on electronic and social media however remains a challenge which needs to be effectively addressed through appropriate legal and administrative frameworks.
Pakistan’s approach towards dealing with Covid-19 is now being lauded globally. However, without going into any complacency and self-congratulatory mode, it is time to learn from this experience. The above lessons must guide us for the future. There may be other lessons and perspectives but the key point is that we need to use this opportunity to take serious stock of the state of our preparation to deal with the next health emergency which may be around the corner. The fact remains that, despite this success, our health emergency related systems, institutions and workforce remain inadequate and weak. The time to prepare for emergencies is when there is no emergency. We have hardly invested in preparing for health emergencies during peace times.
Covid-19 has jolted the world and there is a lot of rethinking about the future of healthcare. For example, Germany has announced investment of four billion euros in the health sector by 2026. Investing in healthcare is investing in human capital and productivity without which economic growth remains a mirage. With the kind of serious health challenges in Pakistan, we have to make a complete paradigm shift on healthcare. It is time to seriously plan Primary Health Care based Universal Health Coverage in the country.