— By Naquia Unwala and Ibrahim Haidar —
The COVID-19 pandemic threatens to overwhelm much of the world’s vulnerable populations as it exacerbates and exposes underlying weaknesses in global health systems. Pakistan, the fifth most populous country in the world, is at an acute risk to the pandemic given the pre-existing challenges to its health system and overall population health status.
A 2017 World Health Organization review of Pakistan’s public health sector identified key shortcomings including the sparsity of healthcare facilities, especially accessibility to medical care and supplies in rural areas, and the widespread nature of communicable disease. These inequities were further corroborated by volunteers on the ground citing insufficient and overcrowded hospital wards and ICUs.
This article presents an assessment of provincial government preparedness to respond to the COVID-19 pandemic in Pakistan. The article also presents summaries of the health status and current healthcare capacity in each of the five provinces, and defines implications for a possible government response. Lastly, this article discusses the current measures being taken in different provinces based on interviews with local NGOs that are responding to the pandemic, as well as proposed responses by Pakistani communities informed by principles in public health responses.
Healthcare Capacity and Health Status
Pakistan’s healthcare system relies on the partnership between private and public sectors providing primary, secondary, and tertiary care centers in its five provocines. The public sector involves a multi-tiered system of care in the form of basic health units (BHUs), rural health centers (RHCs), sub-health centers, and maternity and child health centers. Despite a 14% increase in total healthcare infrastructure from 2000-2015 , the number of healthcare facilities and resources is significantly outnumbered by the growing population, which poses significant implications for the country’s response to COVID-19.
The public sector healthcare system of Pakistan has encountered obstacles such as the scarcity of resources, inaccessibility to rural populations, gender inequities, and structural inefficiencies. In 2015, it was reported that 0.8% of the country’s GDP is spent on the healthcare system, which pales in comparison to the healthcare expenditures of Pakistan’s neighboring countries such as Bangladesh (1.2%). It was reported in 2007 that there was only 1 doctor for every 1225 people, and 12,804 health facilities in the country to cover 170 million people. There is also a significant disparity in the distribution of general practices and health facilities in the country, as 70% of practices are mainly in urban areas despite the fact that approximately 30% of the population lives in these areas. The healthcare system in the country is further weakened by the prevalence of communicable, maternal, and perinatal conditions, such as respiratory infections and cancers, which account for 52.8% of total deaths in the country .
The primary division of healthcare infrastructure in Pakistan falls along its five provinces, which differ in terms of regional healthcare capacity, overall health status, and access to healthcare services.
Punjab, the most populated province with the highest population density in Pakistan, faces weaknesses in healthcare infrastructure emblematic of the larger infrastructural flaws that the country faces as a whole. The primary health concerns in Punjab result from fundamental shortcomings of supply in the healthcare infrastructure. For instance, only about a half of provincial hospitals have access to supplies as basic and essential as blood banks. These phenomena manifest in the fact that communicable disease accounts for an incredible amount of mortality in the province.
In Sindh, rapid urbanization resulted in stark contrast between the urban and rural populations of the province and subsequent severe rural poverty. As a result, concerns such as scarce use of rural facilities and significant shortcomings in health awareness generally permeate the region. Private providers account for a large portion of healthcare infrastructure in the cities, and though there is access to basic services, they are by no means ubiquitous and fall short in number. An example provided by Muhammad Achar Bozdar of the Fast Rural Development Program indicates that only 16% of facilities are capable of taking on ICU patients, a preeminently required service in the wake of COVID-19.
Khyber Pakhtunkhwa (KPK) is the smallest region geographically but the third largest by population. Its primary challenges in healthcare are indicated by social determinants in widespread illiteracy, unemployment, lack of sanitation, and lack of access to food and water. In fact, in the 2017 WHO review, it was found that 38% of children in the region were underweight and malnourished. The healthcare infrastructure of the region also has a history of severe budget cuts in healthcare and a lagging-behind in development caused by such phenomena as frequent flooding. The region faces challenges such as poor governmental management, and increased unavailability of crucial supplies and healthcare workers, which are furthermore divided inequitably throughout the region.
Gilgit-Baltistan is a newly created province within Pakistan’s northern areas with an estimated population of 1 million. There are 5 district hospitals, 27 civil hospitals, 15 BHUs, and 2 RHCs in the region, however the RHCs and BHUs were reported to have insufficient services due to the lack of basic Emergency Obstetric and Newborn Care services and other essential components. The doctor to population ratio in the region (1:4100) is also disproportionate to the national statistic (1:1225), highlighting the stark disparity that the region faces in comparison to other provinces. Water supply shortages, lack of trained nursing staff, and overall challenges to maintaining hospital hygiene and sanitation also mark the healthcare infrastructure of the province, which may pose barriers to responding to the pandemic .
Balochistan is the largest region geographically yet the smallest by far in terms of population. The interspersed nature of its inhabitants indicates that the primary infrastructural concern of the region is providing access to the inhabitants of the region. The existing healthcare facilities are also sparse. Balochistan furthermore has the least developed roads and communication infrastructure and further has low levels of education, scarce access to clean water, and general poor sanitation.
Health Ministry Response Measures to COVID-19
As of March 27th, 2020, Pakistan is reported to have the highest number of COVID-19 cases in South Asia, surpassing that of its heavily populated neighboring country, India . To contain the spread of the virus, the federal and provincial governments have implemented responses such as border closures with neighboring countries, school closures, city lockdowns, mass social distancing orders, quarantining more than 3000 travelers from Iran, and the deployment of Pakistani army troops to aid provincial governments . Yet, testing at scale is severely limited in the country, suggesting that governments may not be able to accurately gauge the extent of the pandemic in certain regions. Should the country experience a spike in cases, pre-existing shortages in personal protective equipment (PPE) and severely limited healthcare capacity will continue to pose pronounced challenges to healthcare workers.
Significant anecdotal evidence from NGO leaders and other healthcare workers in the KPK and Sindh regions further confirms the lack of testing and other inefficiencies in provincial healthcare systems. We interviewed NGO leaders such as Muhammad Achar Bozdar at Fast Rural Development Program and Muhammad Dawood at Takal Welfare Organization to assess the regional government’s preparedness and primary concerns of healthcare capacity in the Sindh and KPK provinces.
Bozdar, one of the Board of Directors at the Fast Rural Development Program, emphasized that although basic healthcare services are available in Sindh, they are still at a considerably low level and are unmatched against the province’s high population. According to Bozdar, only 16% of facilities in the region accept ICU and CCU patients, and only 39% of facilities have separate wards for services, leading to overcrowding in healthcare facilities as patients wait in line to receive attention from the overwhelmed staff. Prior to the pandemic, healthcare facilities in Sindh were already under pressure in terms of the lack of proper resources, such as ventilators and PPE, and COVID-19 has only further exacerbated the gaps in resources at under-equipped hospitals. To address this, the Government of Sindh has been working to increase the access of health facilities to COVID-19 patients by establishing isolation wards to provide treatment in Sukkur, Hyderabad, Karachi, Nawabshah, and Larkana. The Sindh province has also been importing additional testing kits and PPE for frontline workers, and Bozdar stated, “[The] health capacity of the government is not sufficient for all, [but] they are trying.”
Bozdar also noted the significant disparity in care and resources for socially vulnerable groups in Sindh. Rural populations are especially at an elevated risk for experiencing healthcare inequities during the pandemic due to the lack of proximity to healthcare facilities, changes in healthcare systems from low-cost setups to more expensive commercial arrangements, and poor overall health status related to conditions such as malnutrition and malaria. However, according to Bozdar, although the Sindh government has issued a lockdown on both rural and urban cities, the government has been mainly focusing on controlling the spread of the virus in urban areas. Since 40% of the rural population of Sindh is below the poverty line, Bozdar stated, the lockdown holds dire implications for daily laborers in the rural areas who are unable to earn wages and may face extreme food shortages. Women and children are also found to be one of the most affected groups as basic services are already provided on low levels, with basic delivery services for women available at only 55-68% of healthcare facilities (Muhammad Achar Bozdar, 2020).
The healthcare infrastructure in the KPK province has also been reported to have similar challenges as Sindh in terms of minimum-capacity infrastructure and overall preparedness to the COVID-19 pandemic. According to Dawood, the Executive Director at the Takal Welfare Organization, there is a severe lack of proper PPE in the isolated wards set in the region, and at the time of the interview, there was also no public COVID-19 testing facility established in KP and samples were instead forwarded to the screening facilities in Islamabad. As of April 24, though, testing capacity in the region has grown by about 12 times in two weeks, and there are currently about 1200 tests being administered per day . To sustain the amount of PPE in public healthcare facilities in the region and protect frontline workers from potential carriers of the virus, the KPK government closed down all OPDs and elective surgical services in all district headquarter hospitals, tertiary care centers, and private hospitals throughout the province. Dawood also expressed similar concerns as Bozdar in terms of the healthcare inequities which exist in rural populations. Since the KPK government has limited resources, Dawood says, the government mainly focuses on urban areas, and the rural population tends to receive less directives and information from the government.
Discussion and Solutions
After three weeks since reporting the country’s first COVID-19 case in late February, the Pakistani government imposed a one month lockdown to slow the spread of the virus, with the intention of relaxing lockdown measures to mitigate economic burden. According to a study on the progress of the COVID-19 pandemic in Pakistan, an extended shutdown of the country would lead to significant economic loss, and would cause death either due to hunger or COVID-19. A partial shutdown was therefore implemented to encourage social distancing, while also to provide basic necessities to the population, specifically for vulnerable populations and rural communities . An analysis on the efficacy of the lockdown on the spread of the virus in Pakistan also demonstrated a 13.4% increase in cases before the lockdown, which then decreased to 6.55% during the lockdown. However, as restrictions on social gatherings begin to relax, there is a risk of cases increasing and the need to implement a stricter lockdown protocol for the country in the future .
There are several major risk factors to Pakistan in relation to the preparedness of the public healthcare infrastructure. The doctor to patient ratio in certain regions is disproportionate to the national statistic, and healthcare workers are at an elevated risk for acquiring the virus. There are also significant inequities in access to healthcare resources and governmental directives in rural populations compared to urban areas. Shortages in PPE, lack of widespread and adequate testing, and overcrowding in hospital wards will continue to exacerbate the infrastructure of the public health system in Pakistan. Poor health outcomes of marginalized communities in Pakistan and economic barriers to receiving healthcare are also commonplace in certain regions, and may contribute to the disproportionate effect of the virus on vulnerable populations.
Given the challenges to the healthcare infrastructure, dense population, and financial position of Pakistan, the country will require much more facilitation in developing interventions that will limit the spread of COVID-19. To isolate and treat infected individuals, a robust testing system must be implemented in several different cities across the country. Adequate training should also be provided to healthcare workers and laboratory staff to improve testing efficiency. Testing locations must also be accessible to communities where there are severe inequities in healthcare access and quality, such as in the rural areas of the country. Based on anecdotal evidence from Dawood in the KPK province, there is also a need to promote public knowledge to areas that receive less directives from the government regarding the importance of social distancing measures and other risk-mitigating activities. The government must also directly invest into public healthcare infrastructure and services to ensure the adequate supply of PPE and healthcare workers to address the pandemic. Lastly, provincial governments should work with the marginalized communities in their regions to minimize risks of acquiring and spreading the virus, such as providing economic relief funds to daily wage workers. It is imperative that a partnership be built between governments and communities in Pakistan to address the specific needs and inequities prevalent in each province to minimize the risk of COVID-19 spreading.
We would like to thank Muhammad Dawood, Executive Director at Takal Welfare Organization, and Muhammad Achar Bozdar, Board of Director at the Fast Rural Development Program, for speaking with us and providing their insight on the COVID-19 pandemic in Pakistan. We would also like to recognize the efforts of their organizations in providing support to their communities in Pakistan during this time.
- Short Roundup of Health Infrastructure in Pakistan (2000-2015). Gallup Pakistan. https://gallup.com.pk/big-data-analysis-report-1/. Published May 11, 2020. Accessed June 9, 2020.
- Ansari RM, Ansari Y, Ansari SY. Status of General Practice and Challenges to Healthcare System of Pakistan. Open Journal of Preventive Medicine. 2015;05(12):463-467. doi:10.4236/ojpm.2015.512052
- Asif AF. Healthcare Challenges In Gilgit Baltistan: The Way Forward. Pakistan Journal of Public Health. 1970;7(2):113-116. doi:10.32413/pjph.v7i2.47
- Afzal M. Pakistan teeters on the edge of potential disaster with the coronavirus. Brookings. https://www.brookings.edu/blog/order-from-chaos/2020/03/27/pakistan-teeters-on-the-edge-of-potential-disaster-with-the-coronavirus/. Published March 27, 2020. Accessed June 9, 2020.
- IMF acknowledges Pakistan’s response to pandemic. DAWN.COM. https://www.dawn.com/news/1549018. Published April 14, 2020. Accessed June 9, 2020.
- Younus U. An inside look at Pakistan’s COVID-19 response. Atlantic Council. https://www.atlanticcouncil.org/event/an-inside-look-at-pakistans-covid19-response/. Published April 24, 2020. Accessed June 10, 2020.
- Abid KT, Abdul Bari YT, Younas MT, Javaid ST, Imran AT. Progress of COVID-19 Epidemic in Pakistan. Asia Pacific Journal of Public Health. May 2020. doi:10.1177/1010539520927259
- Farooq F, Khan J, Khan MUG. Effect of Lockdown on the spread of COVID-19 in Pakistan. Submitted May 2020.