Expert Speak Health Express
Published on Sep 25, 2020
Pakistan must proceed beyond providing immediate relief to its people by investing in programmes that reduce vulnerability and lead to sustained improvements in livelihoods.
Public policy lessons from Pakistan’s experience with COVID-19 The first case of COVID-19 in Pakistan was announced on 26 February, and an initial lockdown was imposed around a month later on 24 March. The pandemic ‘arrived’ relatively later in Pakistan compared to countries like China, Italy and the US, giving the Pakistani leadership time to prepare and develop a plan to manage the public health crisis. However, because COVID-19 is a new disease and much about which is yet unknown, the policy decisions associated with managing the pandemic are characterised by uncertainty. From the genetic and chemical make-up of the virus, to the treatment drugs and isolation requirements of the disease, a plethora of public policy challenges have emerged.

For developing countries like Pakistan, curbing the spread of the disease by locking down certain sectors has come at the huge cost of people’s welfare.

Many governments responded to the crisis by imposing strict economic lockdowns, forcing many sectors to ‘work from home’. However, for developing countries like Pakistan, curbing the spread of the disease by locking down certain sectors has come at the huge cost of people’s welfare. Around 71 percent of the country’s non-agriculture employment is in the informal sector, where the workforce is largely undocumented, depends on daily wages, and has low levels of social security coverage. The leadership faced a difficult trade-off — imposing economic lockdowns to reduce the disease burden associated with COVID-19, or keeping the economy open to avoid ‘death by poverty’ but risking an already strained health sector. Consequently, Pakistani decision-makers faced an overly complex and interconnected web of economic and social welfare policy challenges. Several public policy lessons have emerged over the past six months, which can be summarised into five main observations.

Lesson 1: The learning curve for COVID-19 is steep; relying on data and evidence-based policy making is paramount to saving lives

Following the World Health Organisation’s announcement in March that COVID-19 was a pandemic, <1> hysteria and panic spread like wildfire across the world. In Pakistan too, decision-makers struggled to assuage public confusion over strategies such as social distancing and working from home, and to dissuade people from turning to quick-fix herbal remedies to treat the disease (which was largely a result of misinformation and myths associated with the infection). By 14 June, Pakistan’s COVID-19 curve peaked at over 6,800 cases a day. By early July, the country’s COVID-19 curve began to decline, with many terming it a “mystery” or “secret” <2>. Yet, officials claim that relying on data — and data alone — led to a decline in numbers. Doctors paid attention to how the disease was managed in countries where the pandemic hit first, administrators imposed ‘smart’ lockdowns in neighbourhoods marked as infection hotspots, and effective (although somewhat delayed) centre-provincial coordination helped in implementing informed policies based on localised data. <3>

Public health policies require dependable statistical databases that are up-to-date and can predict demographic trajectories.

Although the decline in numbers could only be a temporary relief, given the unpredictable nature of the disease, it shows that evidence-based decision-making must be at the core of any public policy framework. Public health policies require dependable statistical databases that are up-to-date and can predict demographic trajectories. Moreover, data for public health must be understood beyond the limited scope of clinical medicine. This calls for a broader and more holistic form of public health management needs to be acknowledged where sustained investments in data from interrelated development sectors is included in the analytical process — water and sanitation conditions, urban development, housing and environmental conditions all impact a country’s public health situation.

Lesson 2: Decisions must be based on an ‘integrated framework’ of top-down and bottom-up policymaking

Pakistan’s experience with decentralisation has been impulsive, correlated closely to the country’s political landscape. The country’s political leadership has found it difficult to divorce the administrative make-up of its governance structure to that of its political climate, which led to public policies that did not reflect development demands at the ‘local level.’ These setbacks became even more pronounced with the onset of COVID-19, where a highly diverse population, differentiated by factors such as geography, language, ethnicity, income and education level, resulted in very varied experiences for COVID-19. For one, disease hotspots emerged in large metropolitan areas, making it an extensively ‘urban phenomenon’. Similarly, public responses varied with wealthier communities voluntarily staying home and following government standardised operating procedures such as wearing facemasks and self-isolating in case of infection. On the other hand, communities associated with daily-wagers and located in crowded housing conditions were unable to follow physical distancing and quarantine guidelines. Moreover, a culture of disbelief in the government coupled with little exposure to scientific data encouraged many to even deny the presence of the pandemic.

Effective policymaking demands an “integrated” approach that merges top-down and bottom-up policies.

Governance for a federal state like Pakistan demands constant coordination between the different tiers of government, which allows for a differentiated response at the local level. Effective policymaking demands an “integrated” approach that merges top-down and bottom-up policies. Such an approach allows for a “cross fertilisation” of macro, meso and local level theories, whereby “a more accurate picture of the local economy for locally suited remedies” can be understood. <4> Such a process can also help establish political consensus, which has been a challenge for the management of COVID-19 in Pakistan. Vertical cooperation between the state authorities could have, for instance, avoided the initial tension that resulted between the Centre and the Sindh province over its independent public health strategy. Similarly, horizontal cooperation across government departments strengthens the enforcement process of public policies. These socio-cultural conditions necessitate that local-level stakeholders are included in the design phase of policymaking as they possess unique insight and knowledge about the communities they inhabit. Furthermore, to facilitate the process of behavioural change that COVID-19 requires, the government must invest in the skills development of local community leaders such as teachers, religious clerics, village elders and primary healthcare workers.

Lesson 3: Invest in the neglected public health sector through sustainable programmes

The COVID-19 pandemic has presented leaders with a unique opportunity to conduct radical policy reforms that were previously inhibited by unproductive governance inertia. Political leaders in middle-income countries like Pakistan often find that short-term, ‘visible’ development projects have higher political outcomes. On the other hand, investing in human capital development through public spending on the health and education sectors yield long-term results beyond their electoral term. Yet, because of COVID-19, there is greater awareness about the necessity of robust healthcare systems. Analysts insist that leaders could become “health heroes” by increasing public spending on healthcare and, as a result, leave behind a legacy of great political value. <5> Included in this endeavour is Prime Minister Imran Khan who has also repeatedly highlighted the need “to focus on building our medical infrastructure” and who has rigorously promoted his ‘Sehat Sahulat’ (health facilitation) programme that aims to alleviate the financial burden of healthcare services. <6> Furthermore, Pakistan was one of the first countries in the world to adopt the UN’s sustainable development goals through a resolution passed by the National Assembly in February 2015, <7> including the commitment to uphold goal 3 (good health and wellbeing), which advocates universal health coverage in an equitable manner.

Investing in human capital development through public spending on the health and education sectors yield long-term results.. because of COVID-19, there is greater awareness about the necessity of robust healthcare systems.

The COVID-19 pandemic has reinforced that health security is a fundamental prerequisite to any socio-cultural, economic and political advancement. Therefore, Pakistan must proceed beyond providing immediate relief to its people by investing in programmes that reduce vulnerability and lead to sustained improvements in livelihoods.

Lesson 4: Public engagement through effective government messaging is instrumental

As the number of COVID-19 cases increased in Pakistan, public sentiment grew weary of government authorities and their ability to manage the spread of the pandemic. By May, many news headlines labelled the leadership’s approach as “confused” or “indecisive”, <8> and the absence of a unified response to the public health crisis became apparent. The decision to keep the Taftan border with Iran open and allow religious pilgrims to enter the country further fuelled controversy over public health management. However, just as Pakistan was being considered one of the worst hit countries by the pandemic, the charts began to indicate a gradual decline and the number of cases fell exponentially. Although various factors are being considered to explain this decline, government representatives insist that a focused and evidence-based approach had a significant role to play. One of the first responses the government employed was to launch informational campaigns about prevention through automated ringtone recordings, text messages, radio and TV advertisements and newspaper infographics.

Political parties need to engage with communities and develop programmes that act as corrective measures to the chronic distrust and low confidence in public authorities.

Nonetheless, for a health emergency like COVID-19, which requires visible behavioural changes and mass adherence to public policies, an important lesson has been the importance of effective public messaging. The leadership’s inability to deliver a unified response, across the federating units and at various government tiers, gave space to chaotic public debates and allowed misinformation to spread uncontrollably. Low public trust in the government is not unique to the current ruling party; studies indicate little public trust in key national institutions has been a recent pattern. ,<9> Therefore, political parties need to engage with communities and develop programmes that act as corrective measures to the chronic distrust and low confidence in public authorities. Moreover, government informational campaigns on best practices with respect to COVID-19 have heavily relied on access to digital resources and information and communication technologies. Given the existing inequalities in terms of internet penetration and access to electricity, coupled with informational asymmetries, the government must deliver innovative information campaigns that engage digitally isolated localities by working with civil society organisations, community leaders and elected local officials. These must also be promoted in local languages to improve understanding and compliance.

Lesson 5: Adopt disaster preparedness and build resilience across the entire governance structure

Given the widespread socioeconomic, environmental and humanitarian impact of the COVID-19 pandemic, a crucial lesson has been to inculcate a culture of preparedness and of building resilience across all public authorities at various tiers of government. In Pakistan, the National Disaster Management Authority (NDMA), established in 2010, is a federal authority, mandated with promoting inter-provincial coordination, preparedness and resilience amongst all relevant stakeholders during a public crisis. Yet, duplication of efforts, such as the launch of the National Coordination Committee of COVID-19 (NCOC), technical limitations and lack of effective inter-departmental communication dilutes the NDMA’s efforts. Nonetheless, disaster preparedness is not limited to the national institution mandated with this objective. Efforts of the NDMA and NCOC must be complemented with capacity-building programmes in the government’s social welfare department, health and education ministries, the environmental protection authorities and local administrative bodies in a continued manner. Additionally, preparedness requires predicting future scenarios and building response plans that depend on reliable and comprehensive data collection exercises. Therefore, Pakistan must expand investments in population and demographic surveys, and epidemiological and topographic research projects.

Efforts of the NDMA and NCOC must be complemented with capacity-building programmes in the government’s social welfare department, health and education ministries, the environmental protection authorities and local administrative bodies in a continued manner.

While conclusive recommendations cannot be made at this stage, there is an urgency to recognise that the COVID-19 pandemic has led to a severe humanitarian crisis across the world, which is still evolving, is cross sectoral and has shaken the foundations of our existing knowledge of public policymaking. Yet, building on shared experiences, Pakistan’s management of the public health crisis provides lessons that can be a learning opportunity for nations with similar socio-cultural, demographic and economic profiles. At the core of this learning process is the need to promote governance models that are participatory, inclusive and representative. In an interconnected world that is ever changing, this demands public policymaking that is adaptive, draws on evidence from diverse disciplines, builds resilience and achieves sustainable development outcomes. <10>
This essay originally appeared in Rebooting the World

Endnotes

At a meeting of the Standing Committee on Scientific and Technological Cooperation in Islamabad, Prime Minister Imran Khan has also gone on record to say, “The pandemic has exposed the need of a much-needed revamp in the medical sector. “We have to focus on building our medical infrastructure so that we are prepared for any such emergency situation in the future.” A 2011 study by Gallup indicated low public confidence levels in key national institutions such as the national government, the judiciary or the police. Likewise a 2015 study on citizen’s confidence in public institutions found that “lack of coordination between Federal & Provincial Government, awareness among people, unstable political environment in country, Political pressure, race for best ratings among channels and Lack of public confidence are the most crucial issues faced by these institutions.” <1>Coronavirus disease pandemic”, WHO, 2020. <2>Experts mull mystery of Pakistan’s falling Covid-19 death rates”, The News, August 22, 2020. <3> “Experts mull mystery of Pakistan’s falling Covid-19 death rates.” <4> Riccardo Crescenzi and Andrés Rodríguez-Pose, “Reconciling top-down and bottom-up development policies”, Environment and Planning A, 43 no. 4 (2011): 773-780. <5> Robert Yates, “Let's Emerge From COVID-19 with Stronger Health Systems”, Chatham House, March 26, 2020. <6> The health insurance program was launched six months into Imran Khan’s premiership. Social welfare has been a priority area on the PTI’s political agenda, however poor governance, implementation loopholes and administrative inefficiencies have challenged progress. To learn more about the program visit. <7>Pakistan’s Implementation of the 2030 Agenda for Sustainable Development: Voluntary National Review”, Government of Pakistan, 2019. <8> Imad Zafar, “What will be the cost of PTI’s indecisiveness during Covid-19?”, The Express Tribune, May 4, 2020. <9> Gallup, “Pakistan’s Troubled State; Naila Yosuf and Binish Nauman, “Examining Citizen’s Confidence in Institutions of Pakistan: An Analysis of Citizen’s Trust”, International Journal of Academic Research in Business and Social Sciences 5, no.5 (May 2015,): 144. <10> “Adaptive Governance”, Stockholm Resilience Centre.
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