Luck or A Strong Response: Why Did Pakistan Fare Relatively Better During COVID?
A review and conversation with Dr. Faisal Sultan, former SAPM Health, Pakistan.
“(Demographic) factors are those that we could not control or influence. But there were very important factors that could be controlled….and we did (control them).”
Dr. Faisal Sultan
On 26th February, 2020 nearly a month after the World Health Organization had declared COVID-19 as a ‘public health emergency of international concern’, the then Special Advisor to Prime Minister (SAPM) of Pakistan on Health, Dr. Zafar Mirza, announced the first two reported cases of COVID-19 in Pakistan [1]. He urged the public not to panic and reassured them that “things [were] under control” [1]. The Pakistani public was not very concerned at this point. Public health professionals, however, were not as indifferent. A BMJ editorial published in March 2020 and authored by leading South Asian public health researchers cautioned that owing to inadequate testing numbers and limited data being generated, the region was far from being prepared for the pandemic [2].
Original illustration by Cassandra Seal.
Pakistan is a lower-middle-income country (LMIC) located in South Asia. With a growing population of nearly 220 million, most of the country’s communities have limited access to health services and were thus extremely vulnerable to the threat of a pandemic. The initial spread of COVID-19 in Pakistan was not as rapid as feared, with cases amounting to just over 1200 in the first month [3]. However, by early March 2020 the country was in its first wave, with the number of cases peaking in June, but then swiftly decreasing. By the end of July 2020, contrary to most models and predictions, Pakistan had flattened the case curve. The fall in cases in Pakistan was surprising, especially compared to neighboring India, where cases surged and the COVID positivity rate rose to 10.4% compared to 3.1% in Pakistan [4]. Even within the region, as of October 2022, the cumulative confirmed COVID-19 deaths per million people were estimated at 129.86 in Pakistan versus 393.45 in Nepal, 373.28 in India, and 171.84 in Bangladesh [4].
Despite a fragmented health system, struggling economy, political instability, and regional insecurity, Pakistan managed to avoid catastrophic numbers of COVID-19 cases. Was this just an impression or did Pakistan actually do better? “[Pakistan] has fared better from a number of perspectives”, says Dr. Faisal Sultan, SAPM on health during the 2020-2022 COVID response. Dr. Sultan counts off the reasons why he says that; first, the per million death count of the country remained low compared to many other countries, second, despite limited facilities and high occupancy the healthy system never got overrun, and third, the country’s economy bounced back much quicker relative to other countries in the region.
There has been much speculation on factors that contributed to Pakistan doing well. COVID-19 morbidity and mortality are higher among the elderly (65yrs +) [5] and Pakistan has a younger population relative to other countries. Dr. Sultan reaffirmed this, elaborating that, “[Pakistan] may have had 3.5 times the deaths if we had population pyramids like Europe.” Another demographic-related reason he mentioned was the rural population, which makes up nearly 63% of Pakistan’s total population “and…is less densely connected”, which would have helped control the spread of disease. This would be contrary to India where the rural population is dense, thus increasing the risk of spread. However, Dr. Sultan is quick to comment that Pakistan’s success is not completely attributable to only these factors, “[Demographic] factors are that we could not control or influence. But there were very important factors that could be controlled - and we did [control them].”
In addition to demographic and social factors, the government’s coordinated response with data-driven strategies supported by a strong public awareness campaign has been recognized as a reason for the successful containment of cases. At the beginning of the pandemic, India imposed one of the harshest lockdowns globally which led to a huge migration of workers from cities to rural areas, pushing the virus all over the country [6]. Conversely, Pakistan chose a lax lockdown that lasted for less than two months. This was followed by, as Dr. Sultan described, “Modulated responses (‘smart lockdowns’) rather than blunt shutdowns” which controlled the spread of COVID-19 yet let the working class find work. The 59.15 million informal workers – nearly 80% of the employed population in Pakistan were at the greatest risk, with reduced income opportunities [7]. Thus, concurrently, the government introduced cash transfers through an existing social safety net program, Ehsaas. Using this government-driven program as a platform, these cash transfers and targeted subsidies to small businesses helped avert an economic crisis.
Additionally, Dr. Sultan attributes the success of the response to multi-sectoral coordination of the military, health ministry, and other ministerial leadership, spearheaded by the National Control and Operation Centre (NCOC). The NCOC, according to Dr. Sultan, based its decisions on data and science and scaled the country’s health service delivery, especially oxygen capacity when needed. He further elaborates, “We used technology for contact tracing, mapping available health facilities, and used AI (artificial intelligence) for mapping disease and responses.”
The COVID vaccination campaign was initiated in the country in February 2021 and within 10 months Pakistan had administered more than 134 million COVID vaccine doses [3]. Starting with Chinese-made vaccines including Sinopharm and CanSinoBio, the program now also includes Pfizer and Moderna vaccines, and has not had any vaccine shortages at any point of the rollout. In the context of being a low- and middle-income country (LMIC), the process of acquisition of vaccines and the rollout has been a triumph [8]. Dr. Sultan explains how timely planning and efficient adaptation aided the government’s COVID vaccine campaign. Once they realized there would be a delay in COVAX delivery, they reassessed their plan and used Chinese vaccine donations to initiate the campaign. This was followed by vaccine purchase and then utilizing the COVAX donation once it arrived. Timely pivoting and prompt allocation of sufficient funds by a dedicated cabinet committee ensured this could happen. Dr. Sultan elaborates “The National Disaster Management Authority took the role (of vaccine acquisition) after mid-summer 2021 to ensure easy procurement…to ensure a vaccination campaign (guided) with a scientific approach, good documentation, and risk targeting.” Though covering a huge population and dealing with vaccine hesitancy, the country’s program has fully vaccinated more than half of the eligible population against COVID by October 2022 [9].
A strong component of Pakistan’s COVID response that Dr. Sultan highlighted was a “good communication campaign.” Guided by data and being responsive to the sociocultural context, the country’s Risk Communication and Community Engagement was quick to share policy and guidelines with the public, establish a 24-hour telephone helpline, replace ringtones with tailored recorded messages, and implement a constant information campaign to counter misinformation [10]. The success of this campaign is evident in its reach: the 12 ringtones developed in a year, with messages relevant to the current COVID situation, reached 167 million mobile phones each day and the helpline responded to nearly 13 million calls in one year [10]. As well, through the COVID response, the government has maintained a public website with a data repository updated in real-time, and disseminated guidelines, and information [3].
Despite the evidence, some question the sensitivity of measurement systems in Pakistan and data quality. Responding to the skeptics, Dr. Sultan points out the accuracy of Pakistan’s reports, “Unless someone posits that the case fatality rate in Pakistan is different from other countries, our numbers are real since they “add up” – including the cases, those in critical care, those dying, and (those utilizing oxygen. Many of these numbers have dual or triple checks for accuracy and ground truthing.” He ends with a smile, “So the questions (from skeptics) are more astonishment and envy, almost!”
However, no response to a pandemic is flawless. Dr. Sultan is cautious and is quick to list things he wishes could have been done differently. He feels Pakistan could have delayed the first lockdown and had less strict travel bans in place, saying the lockdown was “too early” and that travel bans have “limited utility”. He adds, “non-pharmaceutical intervention (NPI) (such as social distancing and mask-wearing) enforcement could have been better but is a challenge in a country with our societal structure….and (to end), we could have had a better ‘thank you’ system for everyone who contributed.” As well, though the existing polio surveillance system was pivoted and utilized for COVID, the country still lacks and could benefit from an efficient surveillance, disease warning, and emergency preparedness system [11].
By no means did Pakistan make it to the lists of countries with the best COVID responses, or those with the least number of COVID cases or deaths, or those with the highest testing rates. Nevertheless, despite the odds, the country did perform much better than the world could have expected. Though demographic and immunological factors contributed, some factors, including data-driven decision-making and a multisectoral response, that ‘could be controlled’ were controlled. A coordinated and locally adaptive health system and communications response helped a LMIC, with a largely illiterate population, to avert disaster and perform better than the region. At any rate, Pakistan, like the world, cannot afford to be complacent. An efficient coping response is not a substitute for building a resilient and robust health system with an emergency preparedness plan and the capacity to respond efficiently when needed [12]. Though Pakistan’s COVID response has revealed strengths, it has also identified gaps in the system. Therefore, this holistic systems-based learning should be leveraged to build back better and be prepared for any future emergencies.
Dr. Amira Khan (she/her) is a Ph.D. candidate at the Department of Nutritional Sciences at the University of Toronto and has completed the Collaborative Specialization in Global Health. A medical doctor, she holds a Diploma in Child Health from Pakistan and a Master of Public Health from the University of Waterloo. She has been part of Dr. Zulfiqar Bhutta's lab at the SickKids Centre for Global Child Health since 2014 and is currently working there part-time as a Research Analyst.
References
[1] Zafar Mirza on Twitter. (2020, February 26). https://twitter.com/zfrmrza/status/1232707169163841537
[2] Bhutta, Z., Basnyat, B., Saha, S., & Laxminarayan, R. (2020). Covid-19 risks and response in South Asia. BMJ, m1190. doi: 10.1136/bmj.m1190
[3] COVID-19 Health Advisory Platform by Ministry of National Health Services Regulations and Coordination. (2021). Retrieved 15 December 2021, from https://covid.gov.pk/
[4] Mathieu, E. (2020, March 5). Coronavirus Pandemic (COVID-19). Our World in Data. https://ourworldindata.org/coronavirus
[5] Verity, R., Okell, L. C., Dorigatti, I., Winskill, P., Whittaker, C., Imai, N., Cuomo-Dannenburg, G., Thompson, H., Walker, P. G. T., Fu, H., Dighe, A., Griffin, J. T., Baguelin, M., Bhatia, S., Boonyasiri, A., Cori, A., Cucunubá, Z., FitzJohn, R., Gaythorpe, K., . . . Ferguson, N. M. (2020). Estimates of the severity of coronavirus disease 2019: a model-based analysis. The Lancet Infectious Diseases, 20(6), 669–677. https://doi.org/10.1016/s1473-3099(20)30243-7
[6] Indian premier apologizes for 'harsh' COVID-19 lockdown. (2021). Retrieved 15 December 2021, from https://www.aa.com.tr/en/asia-pacific/indian-premier-apologizes-for-harsh-covid-19-lockdown/1783763
[7] Markhof, Y. M. (2020). Pakistan’s social protection response to the COVID-19 pandemic: the adequacy of Ehsaas Emergency Cash and the road ahead (Working Paper No. 188). International Policy Centre for Inclusive Growth. https://ipcig.org/sites/default/files/pub/en/WP188_Pakistan_s_social_protection_response_to_the_COVID_19.pdf
[8] Khawar, H., & Prabhu, M. (2021). A million a day: Pakistan’s COVID-19 vaccine campaign hits its stride. Retrieved 15 December 2021, from https://www.gavi.org/vaccineswork/million-day-pakistans-covid-19-vaccine-campaign-hits-its-stride
[9] Mathieu et a. Coronavirus (COVID-19) Vaccinations. (2020). Our World in Data. Retrieved from https://ourworldindata.org/covid-vaccinations?country=%7EPAK
[10] Haq, Z., Mirza, Z., Oyewale, T., & Sultan, F. (2021). Leaving no one behind: Pakistan’s risk communication and community engagement during COVID-19. Journal Of Global Health, 11. doi: 10.7189/jogh.11.03091
[11] Bhutta, Z., Sultan, F., Ikram, A., Haider, A., Hafeez, A., & Islam, M. (2021). Balancing science and public policy in Pakistan’s COVID-19 response. Eastern Mediterranean Health Journal, 27(8), 798-805. doi: 10.26719/emhj.21.016
[12] Lal, A., Erondu, N., Heymann, D., Gitahi, G., & Yates, R. (2021). Fragmented health systems in COVID-19: rectifying the misalignment between global health security and universal health coverage. The Lancet, 397(10268), 61-67. doi: 10.1016/s0140-6736(20)32228-5