As we bid farewell to the year 2020, around 1.7 million people have been killed by the Coronavirus Disease. The Covid-19 pandemic continues to be an unprecedented global challenge that is having devastating effects on public health, economies and societies around the world. Even countries with robust healthcare systems have struggled to cope with this menace. Developing countries like Pakistan, having weak health infrastructures to start with, were presented with the task of not only dealing with the pandemic, but also building systems and responses on the go.

Pakistan’s Covid-19 numbers have remained comparatively low given a population of over two hundred million people. The government was also able to restart the economy in phases. In doing so, it achieved the impossible by also “flattening the curve”. So, how did Pakistan manage the pandemic so much better than what was expected of it?

The central tenet of Pakistan’s effort has been the setting up of a coordinated national response. The government of Pakistan acted quickly to put into place comprehensive coordination mechanisms. This was done by setting up of the National Coordination Committee (NCC) in March – the essential strategic body and its operational arm, the National Command and Operation Centre (NCOC). The NCC, chaired by the prime minister and including provincial leadership, provided strategic direction while the NCOC, a civilian-led and military-supported body, became a one-window operation to collate, analyse and process information based on incoming data and human intelligence and implement the decisions made by NCC on a day-to-day basis.

The federal and provincial bodies worked in synchronisation to ensure an adequate supply of essential equipment like Covid-19 testing kits, personal protective equipment and other essentials like oxygen and ventilators across the country. Additionally, the NCOC served as the single source of reliable information to the public to prevent disinformation and fake news.

After governance, the key was to ensure a smooth flow of data from local to provincial and national level, providing visibility of disease spread as well as health system and capacity utilisation. A resource management system was developed to allow for integrated data visibility of utilisation of the health system capacity across the country. The National Emergency Operations Centre (NEOC) used for polio surveillance was upgraded and tasked to divert 10,000 health facilities and 25,000 workers towards Covid-19 surveillance. Before even the first death was reported in March, polio teams had started Covid-19 sensitivity training for more than 6,000 healthcare workers.

Data in itself is useless unless it is smartly utilised for real-time policy decisions. Multiple modelling groups were using data to predict the disease trends and thus procurement needs, ensuring a forward looking and proactive response to the pandemic.

Pakistan realised quickly, like many low and middle-income countries, that prolonged enforcement of the non-pharmaceutical interventions (NPIs) like closing down public spaces had an unbearable economic fallout, especially for the most marginalised people in our society. Prime Minister Imran Khan ruled out extended national lockdowns over his concern for the economically vulnerable.

Hence, the government formulated strategic targeted interventions that would mitigate the spread of the virus and have a minimal economic impact in limited geographical areas – which came to be labelled as “smart lockdowns”. And while the restrictions were in place, the government provided support to the most vulnerable people via the Ehsaas programme.

The Ehsaas Emergency Cash programme helped the most vulnerable in our country by providing Rs 200 billion in direct relief to the poorest households as well as putting in place critical building blocks for a stronger and deeper financial inclusion of the disadvantaged populations. The programme delivered one-time financial assistance to over 15 million families. This represented almost half of the country’s population. The Ehsaas Emergency Cash project was the largest and most extensive social protection intervention ever in the history of the country, redefining what Pakistanis can expect from their government in time of need.

The National Disaster Management Authority (NDMA) played a pivotal role in procurement and supply of medical equipment to each hospital. With help from the NCOC, the number of facilities with the capability to treat was increased with record speed. Despite global advance bookings, Pakistan secured enough ventilators for use at these facilities. At this moment, Pakistan has more than 16,000 oxygenated hospital beds – nearly 2,800 of which were created with federal help and in record time. A 250-bed infectious diseases hospital in Islamabad was conceived, built, equipped, staffed and made operational within a period of three months. Furthermore, Pakistan built sufficient PPE stock by April and the government-facilitated local production led to a surplus despite a worldwide shortage. Approval was also granted for indigenous production of ventilators.

Pakistan realised quickly, like many low and middle-income countries, that prolonged enforcement of the non-pharmaceutical interventions (NPIs) like closing down public spaces, had an unbearable economic fallout, especially for the most marginalised people in our society. Prime Minister Imran Khan ruled out extended national lockdowns over his concern for the economically vulnerable.

By the end of April, the NDMA and the National Institute of Health (NIH) had worked together to double the number of Covid-19 testing facilities. A further doubling occurred in the coming months so that the current lab capacity stands at 60,000 tests per day. The deployment of PCR tests has been targeted to provide maximum benefit and cost efficiency.

Like war, combating a pandemic is costly. Earlier this year a Fiscal Stimulus Package of Rs 50 billion was provided to meet immediate health needs. An additional Rs 25.3 billion was allocated to the NDMA for supporting the Covid response. Additionally, Rs 70 billion has been allocated for permanently strengthening Pakistan’s health systems. Industries hit the hardest by the imposed restrictions have been provided a relief package to mitigate economic hardship in the private sector. Furthermore, the federal government provided incentives for frontline healthcare workers by giving additional salaries during the first wave.

A test-trace-and-quarantine (TTQ) strategy was developed with effective contact tracing and carried out rigorously to delay community spread of the disease. Innovative technologies were used for surveillance of patients suspected of Covid-19 infection. Local authorities visited individuals that had tested positive and their close contacts. Isolation and home-quarantine measures were evaluated and their testing was fast-tracked.

Effective and frequent Covid-19 risk communication efforts in Pakistan are another aspect of the national response which was highly successful. Four key behaviour modification messages were repeated throughout - use of face masks, emphasis on handwashing, physical distancing and staying at home. The modes of communication included all forms of media: print, electronic, social and caller ringtones. The media played an important role in combating the onslaught of misinformation around Covid-19 patients and timely and credible information from the NCOC actively countered fake news. The polar public perception of threat and politicisation still remains a communication challenge. Efforts are being made to improve risk communication and decrease the polarisation around Covid-19.

To date, more than 70 guidelines ranging from correct use of masks to burial of Covid-19 victims to SOPs for educational institutions and marriage halls have been developed by committees of experts from all provinces and areas. These guidelines have ensured a coherence and evidence-based pandemic response across the country. Being publicly available online, these guidelines serve as an important tool to navigate the threat of the pandemic for provincial and local policy planners, business owners and the public. Thousands of healthcare workers have also received training for frontline work.

In the wake of the second wave of Covid-19, the government put into place guidelines and enforced NPIs tailored to Pakistan’s context which included closure of education institutions, marriage halls and an upper limit on attendance at public gatherings. The unfortunate timing of political rallies, a democratic right of the people, has helped the spread of the disease during a surge of the virus. Risk communication has become particularly difficult as some political leaders are not seen following the SOPs. That is why the prime minister, showing immense leadership, has announced a unilateral moratorium on political rallies of the ruling party and appealed all others to follow suit until the disease transmission wanes.

The rapid incline in cases, hospitalizations and deaths we witnessed in November has been blunted to some extent by these interventions. However, the disease transmission is still high in many major urban centres and citizens must still take precautions against it.

In order to end the acute phase of the pandemic, the government is working on procuring enough vaccines to cover our healthcare workers and the citizens at most risk of severe disease. Many vaccine companies have now started announcing their Phase III clinical trials data, which is showing promising results. Pakistan is currently making arrangements to procure Covid-19 vaccines from various manufacturers and planning to launch its Covid-19 vaccination drive in the first quarter of 2021. We are also a member of UN’s COVAX Facility, a global initiative aimed at equitable access to safe and effective Covid-19 vaccines worldwide.

As 2020 comes to a close, the past few months have brought a lot of suffering for many. Pakistanis have come together and shown the possibilities of a determined nation – but this highlights the need for permanent structures for disease detection and response. We are in the midst of this reform agenda to ensure that our public health systems can take similar future onslaughts and to protect lives and health of our public.

The writer is the Special Assistant to the Prime Minister on National Health Services and is a medical graduate from King Edward Medical College. He has received post graduate training in internal medicine and infectious diseases from the USA and is certified by the American Board of Internal Medicine in these specialties. He is a fellow of the College of Physicians and Surgeons of Pakistan and of the Royal College of Physicians of Edinburgh.