ith a large population - fifth largest in the world - Pakistan has poor health indicators and a weak health infrastructure. Despite the dismal context, several complications and lack of health emergency preparation, Pakistan is counted among the countries that managed Covid-19 relatively effectively. In November 2020, the WHO director general, Dr Tedros, included Pakistan in a list of seven countries whose preparation and response offered lessons for the rest of the world on how to deal with a global pandemic. In January 2022, Pakistan topped The Economist’s normalcy index.

Compared to other large-population countries, the morbidity and mortality due to the Covid-19 pandemic were low in Pakistan. We didn’t resort to long blanket lockdowns and despite the limited capacity of health system, we did relatively well. What went right?

First and foremost, Pakistan acted fast. It took the early warnings of a global pandemic seriously. I established an expert advisory group and chaired its daily early-morning meetings at the National Institute of Health. We had our first meeting on January 15, 2020, although the first case in Pakistan was confirmed on February 26, 2020. As we started airport screening, many eyebrows were raised as if we were acting unnecessarily.

In the first 40 days, we set up stringent screening systems at the airports. As the number of cases started rising, towards the end of March 2020, the National Command and Operation Center, a hybrid civil-military set-up was established following a National Security Committee meeting. This turned out to be the most important decision with regard to epidemic control as it led to a cohesive, consistent and effective national response. The core strengths of the NCOC were its authority, convening power, coordination and approach to making data-driven and consensus-based decisions, efficient implementation and 24/7 monitoring. Health care is primarily a provincial government responsibility, yet strong central coordination was needed in the face of a global pandemic. The NCOC performed that function effectively and orchestrated a truly national response.

After the establishment of the NCOC, Pakistan leapfrogged in beefing up health system capacity and essential public health functions. The political vision was clear, “do not panic, leave no stone unturned to stop the spread of the disease, but do not succumb to elite pressure for a lock down.” The prime minister insisted on not taking away the economic opportunity from the lower conomic class. Confirmed cases were hot-spotted to generate heat maps and a “smart lockdown” strategy was implemented. At the same time, financial support was provided to the poor and small-scale businesses. There was a society-wide effort to help those in need. All stakeholders, from religious scholars, private health sector, business communities and educational institutions to media and transporters were taken aboard. A whole-of-government approach was adopted and there was unprecedented inter-sectoral collaboration.

There was mandatory screening at all entry points. Initially, there were only four laboratories in the country capable of PCR tests for the SARS-Cov-2 virus. The National Institute of Health played a pivotal role in raising the number up to 173 and the daily national capacity to more than 100,000 tests. Surveillance data were gathered by piggybacking on the polio information management system. The National Disaster Management Authority worked hard to procure and supply personal protection gear and the required equipment including testing kits, oxygen and ventilators.

During the first wave (in 2020) it was realised that the hospitals’ capacity for critical care was limited. Private sector hospitals were taken into the loop and 7,000 beds added in no time for patients requiring oxygen and critical care. Innovative use of technology also helped. Home health care for patients in isolation through telemedicine, the use of telecommunication data for contact tracing and the establishment of a 24/7 helpline are examples of this. Telemedicine is now part of routine health care, including for mental health care.

Pakistan also outperformed most countries in vaccinating people against SARS-Cov-2. By September 2022, 90 percent of the eligible population had been vaccinated. This was a remarkable achievement considering Pakistan was a non-vaccine-producing country. The clinical trial of the first vaccine, a Chinese product, was conducted in the country. At a later stage, vaccine was also produced by the NIH through a fill-finish process. Vaccine procurement, through Covid-19 Vaccines Global Access, bilaterally and from the global market was efficient. A robust National Information Management System for Covid vaccination linked to the National Database and Registration Authority also helped.

Keeping people informed about the evolving pandemic and educating them about appropriate safety measures was also a part of of Pakistan’s Covid-19 response. The Federal Ministry of National Health Service, Regulation and Coordination produced more than 100 Covid-related guidance documents and made those available on its website. Apart from a strong and sustained media campaign, an innovative approach was adopted by communicating key messages as telephone ringtone. These messages were heard daily by around 150 million mobile phone users.

A major early challenge was managing the Pakistani students in China. The families of some students rallied and accused the government of being insensitive to their children’s plight but I stood my ground and took the decision not to bring them back immediately. Another major challenge was dealing with the pilgrims returning from Iran who had a high rate of infection. I flew to Taftan border post in an army helicopter and developed a plan for reasonable quarantine.

Against all odds, Pakistan was able to generate a robust, comprehensive and effective national response to the pandemic. There have been many lessons. The real challenge is a systematic review and strengthening of the relevant institutions. There have already been some improvements. For example, the NIH has witnessed a major, long-due reorganisation and establishment of Centres for Disease Control. Still, there are many complications to overcome and implementation of some of the reforms has been slow. There are many gaps, including better emergency preparation; vaccine production; disease surveillance system; and human resource development in public health, especially in field epidemiology; and building health system capacity to absorb a sudden surge in patients requiring critical care.

The writer is a former special assistant to prime minister on health