covid 19 essay in english pakistan

• Fact sheets
• Facts in pictures
• Publications
• Questions and answers
• Tools and toolkits
• Endometriosis
• Excessive heat
• Mental disorders
• Polycystic ovary syndrome
• All countries
• Eastern Mediterranean
• South-East Asia
• Western Pacific
• Data by country
• Country presence 
• Country strengthening 
• Country cooperation strategies 
• News releases
• Feature stories
• Press conferences
• Commentaries
• Photo library
• Afghanistan
• Cholera 
• Coronavirus disease (COVID-19)
• Greater Horn of Africa
• Israel and occupied Palestinian territory
• Disease Outbreak News
• Situation reports
• Weekly Epidemiological Record
• Surveillance
• Health emergency appeal
• International Health Regulations
• Independent Oversight and Advisory Committee
• Classifications
• Data collections
• Global Health Estimates
• Mortality Database
• Sustainable Development Goals
• Health Inequality Monitor
• Global Progress
• World Health Statistics
• Partnerships
• Committees and advisory groups
• Collaborating centres
• Technical teams
• Organizational structure
• Initiatives
• General Programme of Work
• WHO Academy
• Investment in WHO
• WHO Foundation
• External audit
• Financial statements
• Internal audit and investigations 
• Programme Budget
• Results reports
• Governing bodies
• World Health Assembly
• Executive Board
• Member States Portal
• Feature stories /

COVID-19 in Pakistan: WHO fighting tirelessly against the odds

So far Pakistan has fared well in its fight against COVID-19. In a country with over 212 million inhabitants, to date roughly 303 000 cases have been recorded and the curve of new infections has flattened since its peak in May and June.

For a developing country facing other crises, this has been a welcome relief.

At the heart of the country’s battle has been Dr Palitha Mahipala, WHO Representative and Head of Mission, originally from Sri Lanka and based in Islamabad, who has been working around the clock seven days a week since the beginning of the pandemic.

“WHO focuses on different aspects of the COVID-19 response in each country. But in Pakistan, the Organization has been involved on every level and has had a significant impact”, says Dr Mahipala.

WHO had been working on many fronts in Pakistan during the pandemic even before the country recorded any cases.

Policy engagement and expert support

Dr Mahipala acknowledges that he wouldn’t be able to lead WHO’s crucial work without the support of Pakistan’s Ministry of Health, with whom he meets “every day or every other day”.

Working with the Government on high level advocacy and policy dialogue is the first level of WHO’s multi-faceted approach to fight COVID-19 in Pakistan.

“What are the measures the government is taking? What is the highest level of commitment we can have?” These are some of the questions that drive the doctor’s work in the policy area.

Technical assistance is another area of WHO’s work plan.

“From early January, the moment WHO headquarters sent us the technical guidance, I was working the same day with the Minister of Health on our response strategy. At that time, we didn’t have a single case. We didn’t have testing capacity. The first thing we did was to draw up a national action plan according to the pillars identified by WHO,” says Dr Mahipala.

On 23 April 2020, Pakistan launched its Strategic Preparedness and Response Plan , prepared by WHO, as a global online event and platform where it was able to raise US $595 million from donors around the world. The plan and the funds got Pakistan off to a strong start in its fight to stop the spread of COVID-19.

Strengthening points of entry and testing

When Pakistan didn’t have any cases of the new coronavirus, and neighbouring countries such as Iran were recording high numbers, controlling points of entry was crucial. WHO played a strong role in trying to slow the arrival the disease.

In mid-January, WHO and the Ministry of Health began screening potential cases and distributing information pamphlets about the risk of the disease to arriving passengers at Islamabad airport. To protect airport staff, WHO provided training and distributed personal protective equipment (PPE). After working on securing Islamabad airport, Dr Mahipala and WHO teams assessed and strengthened other airports as well as isolation and quarantine centres with the Ministry of Health. 

When asked about Pakistan’s biggest gaps, Dr Mahipala says that in the beginning of the crisis Pakistan could only test about 200 people per day. But WHO quickly helped the country ramp up its testing capacity.

“Within six to eight weeks we were up to 30 000 tests per day. We expanded that further and now we can do more than 50 000 tests per day,” he says.

Once again WHO was involved in all the areas of strengthening Pakistan’s testing capacity. WHO obtained tests, supported the hiring and training of staff to carry out testing, and assessed labs all over the country. The Organization has also been providing staff with PPE, transporting test samples and adding PCR machines to the country’s testing system.

Protecting frontline health workers

WHO has been committed to protecting frontline health workers throughout the crisis and Pakistan is no exception, although sadly there have been casualties.

At the time of speaking, Dr Mahipala says that he knows of more than 6 000 doctors, nurses and paramedics who have been infected as well as some deaths.

To support those who also work to protect the rest of the country population, WHO and the Ministry of Health created the WECARE program, which so far has trained 100 000 health care workers on safety practices. In addition to training, the program supplies PPE and motivational support through videos, TV and radio programs.

Acknowledging the crucial role of health workers, Dr Mahipala says: “We need to recognize them as frontline heroes looking after patients and putting their lives at risk.”

Another stream of WHO’s work in Pakistan is research and development, which has involved undertaking large scale studies of COVID-19 cases by staff in Pakistan and supported by WHO colleagues in Geneva. “That will add knowledge not only to Pakistan but also globally,” the doctor points out.

Success factors

The groundwork WHO and Pakistan have laid on combatting other diseases has been a decisive factor in limiting the severity of the COVID-19 outbreak so far.

From the beginning of the crisis, polio staff carried out surveillance and provided training to frontline health workers. “The polio infrastructure we have and related campaigns were fully utilized for COVID-19,” says Dr Mahipala.

WHO Director-General Dr Tedros  Adhanom Ghebreyesus had previously commended how the country capitalized on its previous work on polio: "Pakistan deployed the infrastructure built up over many years for polio to combat COVID-19. Community health workers who have been trained to go door-to-door vaccinating children have been utilized for surveillance, contact tracing and care."

This success has also helped WHO in Pakistan raise further funds.

With cases at a low level, another problem is arising—complacency among the population in cooperating with public protective measures.

In the current phase of the outbreak, Dr Mahipala and his colleagues are focusing more on communications as a key  aspect of the response.

“We really built on communications channels we set up for polio. Radio penetration is high and so is social media, which we were already using for polio.”

Mobile phone communications has also been key. “Here even people who have barely anything have a mobile phone, or more than one,” he explains.

WHO has also worked with religious groups and scholars to get their messages out in Pakistan.

Despite relative success in the fifth most populous country in the world, COVID-19 has been a formidable challenge.

Dr Mahipala realizes how fortunate Pakistan has been so far and recognizes the dedication of the people who have helped tackle COVID-19.

“There are people who are totally steadfast devoted, who haven’t been home since January.”

But the work goes on, he says.

“We change our strategy as the pandemic evolves. We change our plans as cases rise and fall.”

Read more about WHO’s work in Pakistan

Show your support and donate today

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

Loading metrics

Open Access

Peer-reviewed

Research Article

COVID-19 in Pakistan: A national analysis of five pandemic waves

Roles Conceptualization, Formal analysis, Investigation, Methodology, Software, Validation, Writing – original draft

Affiliation Research and Development Solutions, Islamabad, Pakistan

Roles Conceptualization, Data curation, Formal analysis, Methodology, Software, Validation, Writing – original draft

Roles Conceptualization, Data curation, Investigation, Methodology, Validation, Writing – original draft

Roles Conceptualization, Data curation, Supervision, Validation, Visualization, Writing – review & editing

Affiliations Ministry of National Health Services, Regulation and Coordination, Islamabad, Pakistan, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan

Roles Conceptualization, Investigation, Project administration, Supervision, Validation, Writing – review & editing

Affiliation Akhter Hameed Khan Foundation, Islamabad, Pakistan

Roles Conceptualization, Funding acquisition, Investigation, Project administration, Supervision, Validation, Writing – review & editing

* E-mail: [email protected]

Affiliations Research and Development Solutions, Islamabad, Pakistan, Ministry of National Health Services, Regulation and Coordination, Islamabad, Pakistan

• Taimoor Ahmad, 
• Mujahid Abdullah, 
• Abdul Mueed, 
• Faisal Sultan, 
• Ayesha Khan, 
• Adnan Ahmad Khan

• Published: December 29, 2023
• https://doi.org/10.1371/journal.pone.0281326
• Peer Review
• Reader Comments

The COVID-19 pandemic showed distinct waves where cases ebbed and flowed. While each country had slight, nuanced differences, lessons from each wave with country-specific details provides important lessons for prevention, understanding medical outcomes and the role of vaccines. This paper compares key characteristics from the five different COVID-19 waves in Pakistan.

Data was sourced from daily national situation reports (Sitreps) prepared by the National Emergency Operations Centre (NEOC) in Islamabad. We use specific criteria to define COVID-19 waves. The start of each COVID-19 wave is marked by the day of the lowest number of daily cases preceding a sustained increase, while the end is the day with the lowest number of cases following a 7-days decline, which should be lower than the 7 days following it. Key variables such as COVID-19 tests, cases, and deaths with their rates of change to the peak and then to the trough are used to draw descriptive comparisons. Additionally, a linear regression model estimates daily new COVID-19 deaths in Pakistan.

Pakistan saw five distinct waves, each of which displayed the typical topology of a complete infectious disease epidemic. The time from wave-start to peak became progressively shorter, and from wave-peak to trough, progressively longer. Each wave appears to also be getting shorter, except for wave 4, which lasted longer than wave 3. A one percent increase in vaccinations decreased deaths by 0.38% (95% CI: -0.67, -0.08) in wave 5 and the association is statistically significant.

Each wave displayed distinct characteristics that must be interpreted in the context of the level of response and the variant driving the epidemic. Key indicators suggest that COVID-19 preventive measures kept pace with the disease. Waves 1 and 2 were mainly about prevention and learning how to clinically manage patients. Vaccination started late during wave 3 and its impact on hospitalizations and deaths became visible in wave 5. The impact of highly virulent strains Alpha/B.1.1.7 and Delta/B.1.617.2 variants during wave 3 and milder but more infectious Omicron/B.1.1.529 during wave 5 are apparent.

Citation: Ahmad T, Abdullah M, Mueed A, Sultan F, Khan A, Khan AA (2023) COVID-19 in Pakistan: A national analysis of five pandemic waves. PLoS ONE 18(12): e0281326. https://doi.org/10.1371/journal.pone.0281326

Editor: Huzaifa Ahmad Cheema, King Edward Medical University, PAKISTAN

Received: January 20, 2023; Accepted: December 12, 2023; Published: December 29, 2023

Copyright: © 2023 Ahmad et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data was provided to the Akhter Hameed Khan Foundation (AHK-F) team for this study as part of its work with Pakistan’s Federal Ministry of National Health Services, Regulations & Coordination (MoNHSR&C) and the National Command & Operation Centre (NCOC) in Islamabad, which are leading Pakistan’s response to the COVID-19 pandemic. The AHK-F team has provided analytical support to the above entities, and such created knowledge that has directly informed pandemic policy-making in Pakistan. COVID-19 data is compiled and shared in daily National Situation Reports, or Sitreps, by the National Emergency Operation Centre (NEOC). Each day’s Sitrep is compiled as a PDF file. The data used for this study was manually compiled from these PDF files and then used in STATA. The parentage of this data is with the NCOC and the MoNHSR&C. The AHK-F team received this data with the express understanding that it would be kept confidential. However, the data can be obtained independently from the NEOC, through a data request procedure, which is subject to approval from the MoNHSR&C. The data request itself is to be addressed to: Dr. Shahzad Baig, National Coordinator, National Emergency & Operation Center, D Block, EPI Building, Chak Shahzad, Park Road, Islamabad. Email: [email protected] Phone: +92-51-8730879. The data on Oxford Health and Containment Index is taken from and publicly available at the following GitHub repository: https://github.com/OxCGRT/covid-policy-tracker/tree/master/data .

Funding: This work was supported, in whole or in part, by the Bill & Melinda Gates Foundation [grant number: INV-025171]. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

In Pakistan, the first case of COVID-19, a novel and little-understood disease, was detected on February 26, 2020. Being a developing country with limited resources, crumbling health infrastructure and low health expenditure [ 1 ], Pakistan has no past experience with pandemics and a high burden of communicable diseases [ 2 ]. As of February 23, 2022, the country had fully vaccinated 43% of its total population [ 3 ] and the Omicron variant of COVID-19 was the dominant strain [ 4 ]. These factors make Pakistan a high-risk country, with a large pool of infection-susceptible people.

The emergence of COVID-19 has arguably been the biggest social and economic disruption in Pakistan in recent history. The pandemic has largely manifested itself in five distinct waves each of which have a rise, plateau, and trough in cases, followed by a period of dormancy, after which the incidence of COVID-19 infections begins to rise again. Thus, each individual wave follows a four-stage pattern followed by endemicity that has been seen for many infectious disease epidemics [ 5 ]. Beyond anecdotal observation, there is evidence that this is happening with COVID-19 as well [ 6 ]. What sets COVID-19 apart is that after completion of an individual wave, a new one would come along shortly, rather than taking much long, for example, annual recurrences for influenza. This pattern has been seen across the globe [ 7 – 11 ] with the timing of COVID-19 waves in different countries broadly coinciding [ 6 ].

In this context, current literature on COVID-19 largely focuses on high-income countries during the initial waves [ 7 , 12 , 13 ], or aggregated at regional levels [ 8 , 14 ]. Given the different capacities of countries to manage the pandemic [ 15 ], there is a need to explore the characteristics of the subsequent pandemic waves in a developing country context, preferably with granularity of a country-level analysis.

This paper aims to offer a comprehensive understanding of the impact of COVID-19 in Pakistan. To achieve this, we examine the five waves of the pandemic in Pakistan, analyzing various key aspects and critical statistics. These include the total number of COVID-19 tests conducted, confirmed cases, hospitalizations, COVID-19-related deaths, and the progress of vaccinations during each wave. Additionally, we employ statistical modeling to identify the significant factors contributing to COVID-19-related deaths. Our goal is to fill the existing gap in the literature by providing valuable insights specific to a developing country like Pakistan, where limited evidence currently exists.

Criteria for COVID-19 waves

We begin by retrospectively defining various time periods between 2020 and 2022 as distinct waves, based on existing literature [ 16 ]. There are a total of 628 observations (daily set of indicators) across these five waves. Based on our criteria, the starting point of each COVID-19 wave is defined as the day with the lowest number of daily new COVID-19 cases preceding a consistent rise in these cases, before the peak of the respective COVID-19 waves. The end of each wave is defined as the day with lowest number of daily new COVID-19 cases following a 7-day decline; this number also needed to be lower than the cases on any of the 7 days that followed it ( Table 2 ).

Data and variables

In order to estimate the pattern for COVID-19 throughout the five waves in Pakistan, we use time series data of various daily indicators from April 3, 2020 to February 23, 2022, which are categorized into the following broad themes:

• i) Wave timespan
• ii) COVID-19 tests
• iii) COVID-19 cases
• iv) Test-to-case ratio
• v) COVID-19 positivity
• vi) Hospitalization and treatment
• vii) COVID-19 deaths
• viii) COVID-19 vaccination
• ix) Policy environment

Several variables in the list above were transformed into ratios for the purpose of describing all five COVID-19 waves in Pakistan ( S1 Table ).

The data for all but two of the above themes, COVID-19 vaccination and policy environment, is compiled from daily national situation reports (Sitreps). These Sitreps are prepared by the National Emergency Operations Centre (NEOC) in Islamabad, Pakistan. Data in these Sitreps have served as the basis for all major COVID-19 policy decisions in Pakistan.

The data for COVID-19 vaccination is sourced directly from the National Command & Operation Centre (NCOC), Islamabad, Pakistan, which is the government forum that brings together the ministries of Health and Planning along with the military to determine pandemic policy and to coordinate the response. Data for the policy environment is taken from a publicly available dataset from the University of Oxford’s Blavatnik School of Governance [ 17 ]. This dataset is compiled by using qualitative information about the non-pharmaceutical interventions (NPIs) in a country and quantifying them into an index called Oxford Containment and Health Index for COVID-19. A detailed methodology of the index calculation can be found in a working paper by the Blavatnik school [ 18 ].

Model specification

Apart from presenting statistics on daily indicators for every wave, we estimate the predictors of daily new deaths due to COVID-19. For our model of daily new COVID-19 deaths, we use a linear ordinary least square (OLS) regression. The data as well as the model is divided into five distinct periods, representing the five waves of COVID-19 in Pakistan, as of February 2022. The manuscript comprises statistical analysis and inferences for each of the five waves separately.

Our independent variables measured at daily intervals are:

• i) Log of daily new COVID-19 cases with 21-day delay ( LnX1 t+21 );
• ii) Log of daily new COVID-19 tests with 28-day delay ( LnX2 t+28 );
• iii) The Oxford containment and health index for COVID-19 with 14-day delay ( X3 t+14 );
• iv) Time variable capturing the time trend ( X4 t );
• v) The number of people on ventilators as a proportion of the total admitted ( X5 t );
• vi) The number of people on oxygen as a portion of the total admitted ( X6 t );
• vii) Log of second doses of COVID-19 vaccines administered with 14-day delay ( LnX7 t+14 )

Daily new COVID-19 cases are regressed with a 21-day lag, since among those who die from COVID-19 infection, death occurs between a median of 14 days [ 19 ] and 25 days (average of three weeks) after presenting symptoms [ 20 , 21 ]. This is pertinent in the case of Pakistan, as most of the COVID-19 testing in the country has been symptomatic, i.e., done when someone develops symptoms of COVID-19 and hence either voluntarily gets tested or is prescribed by a medical professional to do so.

Given the delay for daily new cases, daily new COVID-19 tests are regressed with a delay of 28 days. This delay allows for the time it takes for someone to test positive for COVID-19 and for their symptoms to worsen (for example, by escalating to hospitalization, which takes nearly a week [ 22 ] before resulting in death). For vaccination, a 14-day lag is taken, as immunity from vaccines is generally understood to develop two weeks or longer after receiving a shot [ 23 – 25 ].

The Oxford Containment and Health Index is calculated out of 100 where 100 means strict restrictions and 0 means no restrictions imposed on the general population. This variable is regressed with a 14-day lag, as we assume that any new government restrictions will take approximately that long to have any effect. Additionally, the time variable is meant to capture any unmeasured or seasonal effects on COVID-19 deaths in Pakistan, such as an overall rate of increase or decrease of daily deaths in each wave. We assume the error term is not correlated with any of the independent variables.

Newey-West standard errors are used to account for autocorrelation and potential heteroskedasticity in the error terms. Statistical tests are performed to ensure that the required assumptions for the regression model are met: for heteroskedasticity, the Breusch-Pagan test is applied, whereas for serial correlation, the Durbin-Watson test is used. Variance inflation factor (VIF) is calculated for multicollinearity. The presence of unit roots is tested using augmented Dicky-Fuller tests for each independent variable in our regression model. All the variables are found to be stationary, fulfilling an important pre-requisite for our analysis ( Table 1 ). The statistical analysis is carried out using STATA 17 software.

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0281326.t001

Summary statistics

Pakistan experienced five distinct waves from 3 rd April 2020 till 23 rd February 2022 ( Fig 1 ). Wave 1 lasted the longest (150 days), while the wave 5 was the shortest (83 days). Wave 4 was remarkable for its relatively rapid upslope and a long tail, while wave 5 showed a reverse pattern. The duration of each wave of COVID-19 in Pakistan was shorter than the preceding one apart from wave 4. After wave 1, each wave took less time to reach its peak and took longer to reach its trough, apart from wave 5.

https://doi.org/10.1371/journal.pone.0281326.g001

The capacity to conduct tests expanded over time from an average of 17,142 tests daily during wave 1 to 49,650 during wave 5. The increase in the daily tests peaked during wave 4. The highest average daily number of cases (3147) were observed during wave 3. The rate of increase of COVID-19 cases was the highest during wave 4, but the rate of decline in cases after the peak of a wave was the fastest during wave 5. Test-to-case ratio kept increasing from 15 during wave 1 to 57 during the wave 5. While total positivity varied across waves, the rate in daily change of positivity remained relatively unchanged apart from waves 2 and 3, where it was lower as compared to other waves ( Table 2 ).

https://doi.org/10.1371/journal.pone.0281326.t002

Hospitalizations were the highest for waves 1 and 3 and the lowest for wave 5, whereas duration of hospitalization fell linearly from an initial 13 days during wave 2 to 5 days during wave 5. Hospitalizations became more specific over time in that, nearly two thirds of admitted patients during wave 1 were stable, compared to 9% during wave 5. The average stable-admitted ratio decreased continuously from wave 1 to wave 4 but increased slightly in wave 5. The rate at which people recovered from COVID-19 and/or were discharged from hospital was the fastest in wave 4 but the slowest in wave 2.

The average oxygen beds-admitted ratio continuously increased in each wave, reaching its maximum value in wave 4. During wave 1, 27% of all admissions required oxygen and 7% needed a ventilator, compared to 81% and 10% respectively during wave 5. The average oxygen bed utilization followed a declining trend except for wave 3 (24%) and was the lowest in wave 5 (7%). The trend of average ventilators utilization ratio showed that all available ventilators were not fully utilized in any of the five waves. The highest ventilators utilization was in wave 3 (20%) and the lowest in wave 5 (5%). These two ratios suggest that most critical patients were put on oxygen for recovery and a small proportion of these people were transferred to ventilators.

Deaths from COVID-19 were the highest during wave 3 at 9,423, which also saw the highest daily number of deaths (78.5) and the highest rate of increase in daily deaths. Average daily deaths to hospitalization rate peaked during wave 2, while deaths to ventilator use was the highest during wave 1. Average deaths to case ratio was the highest for wave 3 but was in the 2.2–2.8% range, except for wave 5 when it was 1.1%.

Pakistan’s vaccination drive started towards the end of wave 2, but full vaccination (i.e., people receiving both their doses) did not happen until the beginning of wave 3. Consequently, total and daily new second dose of vaccine administered was highest in wave 5. Government restrictions, measured by the Oxford Containment and Health Index, appeared to be comparable in each wave.

OLS regression results

The linear OLS regression results for daily new COVID-19 deaths indicate that daily new COVID-19 cases were a statistically significant determinant for daily new deaths in all five waves at 95% CI; a one-percentage increase in COVID-19 cases caused a 0.46–0.69% increase in deaths across the five waves ( Table 3 ).

https://doi.org/10.1371/journal.pone.0281326.t003

The daily new COVID-19 tests and Oxford containment and health index, which records the presence of government NPIs and restrictions, were both found to be statistically significant determinants of COVID-19 deaths in wave 1. Increasing daily new tests by 1% reduced daily deaths by 0.65% (95% CI: 0.26, 1.04). An increase in Oxford Containment and Health Index by 1 point resulted in 0.03% reduction in daily new deaths (95% CI: -0.05, -0.005).

The time trend variable was statistically significant in waves 1, 3 and 4. The coefficients indicate that, on average, daily COVID-19 deaths decreased at a rate of 0.04% per day (95% CI: -0.04, -0.03) during wave 1. However, daily new deaths reduced at a rate of 0.01% per day during wave 3 (95% CI: -0.02, 0.002) and wave 4 (95% CI: -0.01, 0.00).

The ventilator-admitted ratio was statistically significant in waves 1, 4 and 5. The coefficient was negative throughout these three waves and significant at 95% CI. The coefficients indicates that if ratio of patients on ventilator out of the admitted increased then daily new deaths would decrease by 14–17%.

Oxygen-admitted ratio was only significant in waves 1 and 2 at 95% CI, where the coefficient was positive, implying that an increase in the ratio of oxygenated patients out of the total admitted increased was associated with an increase in daily new deaths due to COVID-19 by approximately 4%.

Lastly, the number of fully vaccinated people is statistically significant in each of the last three waves. During wave 3, COVID-19 deaths increased by 0.07% (95% CI: 0.006,0.14) as percentage of fully vaccinated people increased by one percent. This rate increased to 0.10% (95% CI: 0.006,0.14) during wave 4. However, during wave 5, daily new deaths due to COVID-19 decreased by 0.38% (95% CI: -0.67, -0.08) as fully vaccinated people increased.

Pakistan experienced 5 distinct waves from 3 rd April 2020 to 23 rd February 2022. Our analysis reflects both the evolution of Pakistan’s response, as well as the differential impact of different variants of the virus shaped the contours and features of each wave. Pakistan experienced its initial wave earlier than other South Asian countries including India, Bangladesh, Sri Lanka and Nepal, while peaks for the subsequent waves coincided with those in other countries [ 26 ].

The upslope, as seen by the rate of change for testing and cases, was always steeper than during the downward slope of a wave. This pattern follows what is known about infectious epidemics in that cases rise quickly, plateau and then fall, slowly to an endemic state where a low ebb of infections persists in the community indefinitely [ 5 ]. In fact, each wave behaved as a typical epidemic caused by a distinct variant of the virus. Wave 1 was dominated by B.1 variant, wave 2 by B.1.36 variant, the wave 3 by Alpha/B1.1.7 and Delta/B.1.617.2 variants, wave 4 had majority cases of the Delta/B.1.617.2 variant [ 27 – 29 ] while wave 5 was driven by Omicron/BA.5.2.1.7 [ 4 ].

A key challenge faced by Pakistan at the beginning of the pandemic was that there was little prior experience with any pandemic outbreak of such level. Although disease surveillance systems exist, they had not been scaled to manage case surveillance, hospital admissions, daily deaths, and eventually large-scale adult vaccination and event tracking. Pakistan has a federal system of governance where provinces provide health services while the federal ministry provides guidance and coordination. In addition, considerable curative care is in the private sector. To address the potential difficulties in mounting a unified national response to the disease in the face of this diversity, a National Action Plan for COVID-19 was formulated in March 2020 that placed the responsibility for the national response in a National Coordination Committee (NCC) that was headed by the Prime Minister and attended by all federal ministers. The NCC set national policy which was implemented by the National Command and Operation Centre (NCOC) that was co-headed by the military and civilian leadership [ 30 ]. The NCOC coordinated the management of the extensive lockdowns, other key NPIs such as school closures, limited opening hours for essential businesses (examples of which included grocery stores and pharmacies), closure of borders, cancellation of public events and social gatherings [ 31 , 32 ]. This was supported based on an elaborate data gathering and analysis system that guided daily decisions.

Wave 1 continued the longest and intervals became shorter between each successive wave. Each wave showed unique features, that were determined by the particular variant that drove that wave, along with the larger context that included the type of the variant driving the wave, the extent and type of preventive interventions and eventually the availability of the vaccine.

Pakistan’s response to COVID-19 evolved over time. For example, wave 1 had the highest positivity rates and the longest duration, in part due to low initial rates of testing, including very little contact tracing in the early days [ 33 ]. As testing increased and mobility restrictions tightened, duration of waves 2 and 3 became shorter. However, by the end of wave 2, intervention fatigue had set in. Implementation was laxer, and these factors contributed to more cases and deaths of any wave during wave 3. Indeed, the Oxford Containment and Health Index was significant only during wave 1 in terms of preventing deaths.

In addition to preventive measures, the higher daily COVID-19 cases in waves 3, 4, and 5 may be attributed to highly transmissible Alpha [ 34 , 35 ], Delta [ 36 , 37 ] and Omicron [ 38 ] variants, and to easing of severe restrictions such as lockdowns and school closures [ 39 ]. It is also possible that many cases were missed during wave 1 due to limited testing. However, the stability of daily testing in waves 3 to 5 suggests a stable equilibrium between the testing system and how cases were being incident–the system was capturing most of the cases from previously recognized populations and locations. It is likely that undiagnosed cases and deaths were few, since as part of the national surveillance, teams kept abreast of burials in large and midsized towns and also periodically canvased opinion of general practitioners about upsurges in respiratory illnesses. On average, Pakistan had fewer cases per million population than neighboring countries of India, Bangladesh, and Iran, as well as several of the developed countries [ 26 ].

As with prevention, clinical management of cases evolved over time. Initially most cases were hospitalized as seen by the high case to hospitalization ratio–only 27% of admissions required oxygen 7% required ventilators during wave 1. In fact, there was a correlation between deaths and oxygenation (which was mostly at hospitals) during waves 1 and 2, a pattern that was seen globally. However, with each succeeding wave, use of oxygen increased while ventilators fluctuated within a narrow range, as was also seen in India [ 40 , 41 ]. Thus, even as COVID-19 hospitalizations peaked during wave 3, hospitalization to case ratio increased, and average duration of hospitalization and the use of hospitals for simple oxygenation fell, suggesting hospitals, ICU and ventilators, were increasingly reserved only for the sickest [ 42 ]. Deaths correlated best with a 21-day delay model rather than a 28-day one, suggesting that most deaths happened early after infection. Higher hospitalizations during wave 3 may also have been attributed to the Alpha followed by Delta variants [ 43 – 45 ]. By contrast, lower hospitalizations, length of stay, and mortality during wave 5 may be attributed to the Omicron variant that was seen worldwide [ 46 , 47 ], and specifically in South Africa [ 48 ] and Brazil [ 49 ] during the Omicron waves. Vaccination started earlier on in wave 3 and more than half of the eligible population was fully vaccinated by wave 5 [ 3 ] and may have contributed to lower hospitalizations in wave 5. Unlike COVID-19 induced major challenges to the healthcare capacity in various countries [ 50 , 51 ], Pakistan was able to build healthcare resources capacity to keep pace with the pandemic. Ventilator and oxygen utilization never exceeded 20% and 24% respectively in wave 3.

Vaccination drive started in Pakistan by the end of February 2021. Despite a slow start, vaccination picked up pace from 26,356 daily vaccinations in wave 3 to 308,129 in wave 4 as it was rolled-out to younger population and vaccine supply increased in the country. Average daily deaths did not reduce significantly due to vaccinations during waves 3 and 4 [ 52 , 53 ], but showed marked reduction in hospitalizations and deaths towards the end of wave 4 and during the entire wave 5 [ 54 ].

From our regression model, we found that daily new COVID-19 cases were statistically significant determinants of daily new deaths due to COVID-19. The association was also observed from the wave 3 as both cumulative cases and deaths were the highest, including the average daily deaths which were considerably higher than any other wave, as seen in other countries [ 55 ]. Secondly, daily new deaths due to COVID-19 increased with patients on oxygenated beds while decreased with patients on ventilators in the initial waves, potentially due to high patients load in hospitals, critical patients were put on oxygen rather than ventilator. Wave 5 experienced the smallest number of daily COVID-19 deaths possibly because it was dominated by the Omicron variant [ 56 ].

Limitations

There are several limitations associated with the data used in this paper. While the official data used for the analysis are disaggregated by sub-national level, demographic disaggregation, such as age or gender, are not available. This limits the analysis in terms of the implication of gender and age on COVID-19 deaths. The national data is compiled by aggregating the numbers for each subnational unit in Pakistan. However, such an analysis would be too extensive to depict and therefore our analysis does not account for subnational differences. It is possible that distinctive cultures, behaviors, and differences in the stringency in enforcement of interventions vary between regions and may in theory, influence the number of COVID-19 cases and deaths.

Similarly, data for hospitalizations is also unaccompanied by any information on comorbidities, as this information was not available beyond treating hospitals, losing a level of richness of analysis that includes such comorbidities. Also, data for daily new hospital admissions started becoming available towards the very end of wave 1. Consequently, the average length of hospital stay could not be calculated for this wave.

The official vaccination data available to us at the time of this analysis is not desegregated by the different types of available vaccines, for example Sinopharm, CanSino, Sputnik V and others. Differential impact of each vaccine on COVID-19 deaths in Pakistan would be informative. All the above limitations notwithstanding, we are confident that this study provides crucial insights into the prevailing trends of COVID-19 in Pakistan in manner that is constructive.

We describe how COVID-19 waves differed in terms of cases, hospitalizations, and deaths in Pakistan, and analyze potential reasons for these differences. Pakistan experienced its initial COVID-19 wave earlier than other South Asian countries, with wave 1 lasting the longest. As testing increased and restrictions were enforced, subsequent waves became shorter, but wave 3 stood out due to lax implementation, resulting in the highest number of cases and deaths. The higher daily cases in waves 3, 4, and 5 were also attributed to the highly infectious Delta and Omicron variants. Wave 3 recorded the most COVID-19 deaths, with 9,423 fatalities, the highest daily death rate, and the steepest increase in daily deaths. Lastly, vaccination began in wave 2, with full vaccination achieved in wave 3, and the highest second-dose vaccinations occurred in wave 5.

At the pandemic’s onset, Pakistan’s lack of prior experience was a challenge. However, a National Action Plan for COVID-19 was established in March 2020. COVID-19 management in Pakistan kept pace with the spread of the disease during five distinct waves and successfully implemented the COVID-19 vaccination drive nationwide. The experiences and limitations offer valuable insights for future pandemic management for a developing country like Pakistan.

Supporting information

S1 table. calculated ratio variables and their descriptions..

https://doi.org/10.1371/journal.pone.0281326.s001

• 1. Noreen N, Dil S, Ullah S, Niazi K, Naveed I, Khan NU, et al. Coronavirus disease (COVID-19) Pandemic and Pakistan; Limitations and Gaps. Global Biosecurity. 2020;1. https://jglobalbiosecurity.com/articles/63/galley/170/download/ .
• View Article
• PubMed/NCBI
• Google Scholar
• 3. NCOC. Vaccine Statistics. 2022 [cited 23 Feb 2022] p. NCOC Official Website. https://covid.gov.pk/vaccine-details .
• 4. Badar N, Ikram A, Salman M, Umair M, Rehman Z, Ahad A, et al. Genomic characterization of SARS-CoV-2 from Islamabad, Pakistan by Rapid Nanopore sequencing.
• 17. OxCGRT. OxCGRT COVID Policy Tracker Data. 2021. https://github.com/OxCGRT/covid-policy-tracker/tree/master/data/timeseries .
• 18. Hale T, Anania J, Angrist N, Boby T, Cameron-Blake E, Folco M Di, et al. Variation in government responses to COVID-19, Version 12.0. BSG Working Paper Series. 2021.
• 26. Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, et al. Coronavirus Pandemic (COVID-19). In: OurWorldInData.org [Internet]. 2020. https://ourworldindata.org/coronavirus .
• 30. National Institute of Health Pakistan. National Action Plan for Corona virus disease (COVID-19) Pakistan. 2020.
• 31. Gul A. Pakistan Seals Borders, Shuts Schools, Bans Public Events Over Coronavirus. Voanews.com. 13 Mar 2020: COVID-19 Pandemic.
• 38. Tian D, Sun Y, Xu H, Ye Q. The emergence and epidemic characteristics of the highly mutated SARS-CoV-2 Omicron variant. 2022.
• 39. Provinces announce easing lockdown even as Pakistan witnesses record rise in coronavirus cases. In: DAWN [Internet]. 2020 [cited 1 Aug 2022]. https://www.dawn.com/news/1555575 .

• français
• español
• português

Related Links

Pakistan: a primary health care case study in the context of the covid-19 pandemic.

View Statistics

Description, collections.

• Publications

Show Statistical Information

• 1. Headquarters

• How We Work
• CrisisWatch
• Upcoming Events
• Event Recordings
• Afrique 360
• Hold Your Fire
• Ripple Effect
• War & Peace
• Photography
• For Journalists
• Download PDF
• Early Missteps
• Pandemic Policy in Pakistan’s Fractured Polity
• Mixed Messaging and the Power of the Pulpit
• The Economy, Health Policy and Social Support
• Health Systems in a Pandemic

Pakistan’s COVID-19 Crisis

A federal government misstep – lifting a lockdown too soon – has placed Pakistan among the twelve countries hardest hit by coronavirus. Nor has the economy recovered as intended. Authorities should let provinces make more health decisions and focus on helping citizens in need.

• "> Download PDF

What’s new?  Hoping to mitigate COVID-19’s economic toll, Imran Khan’s Pakistan Tehreek-e-Insaf government lifted a countrywide lockdown in May, leading to a spike in cases. August could see another surge since the public, misled by the clergy and mixed messaging from the government itself, may disregard precautions during religious festivities and ceremonies.

Why does it matter?  Climbing infection rates could overwhelm ill-equipped health systems and hinder economic recovery. If citizens are denied health care or adequate aid as the economy contracts, public anger is likely to mount, potentially threatening social order. Militants could take advantage, as they have in the past.

What should be done?  The federal government should guide provinces on pandemic policy and help reinforce their health systems but also permit them to devise their own local strategies guided by medical experts. It should work with the parliamentary opposition on its response, particularly on providing a safety net to vulnerable parts of society.

I. Overview

On 9 May, the Pakistan Tehreek-e-Insaf government almost completely lifted a nationwide lockdown it had imposed in late March to counter COVID-19. Pakistan subsequently saw a surge in cases, placing it among the top twelve pandemic-affected countries worldwide. The government justifies the easing of nationwide restrictions on economic grounds; indeed, the lockdown’s toll on the most vulnerable, workers and the poor has been brutal. Yet signs of economic recovery since it was lifted are few, while the virus threatens to overwhelm ill-equipped and under-funded health systems. Rising anger and alienation among citizens could threaten social order, potentially giving militants an opening to gain support. The federal government should revise its approach. It should seek consensus with political rivals on its coronavirus strategy, pay greater heed to public health experts, if feasible step up aid to families unable to get by and give the provinces more leeway to lead local efforts to deal with the public health crisis.

The government’s mixed messaging and misinformation from some religious leaders mean that many Pakistanis disregard public health advice. Prime Minister Imran Khan’s initial downplaying of the pandemic’s health risks led to widespread public disregard for social distancing procedures. The removal of restrictions on communal prayers in mosques also increased the risks of new virus clusters. Many clerics advocate religious practices that undercut physical distancing and other preventive measures; they tell worshippers that piety alone, and not health practices, will determine their fate. The federal government’s easing of lockdown measures, despite warnings by the political opposition and medical professionals that transmissions would surge, and the further lifting of the lockdown, on 9 May, encouraged public complacency. Though the government now urges people to respect social distancing rules, these calls are largely ignored. Many believe that the pandemic is over.

The federal government’s adoption of what it calls a “smart lockdowns” strategy may not be enough. The strategy entails removing restrictions in specific areas within cities or regions where the authorities assess that case rates are relatively low and imposing them where they are high. But poor data and low testing rates have hampered efforts to “track, trace and quarantine”, which involve identifying and isolating virus carriers and their contacts and placing hot-spots under quarantine, and are essential to curbing the virus. With COVID-19 spreading in densely populated cities such as Karachi, Lahore and Peshawar, limited closures are unlikely to prevent contagion. While city hospitals are better prepared to deal with the pandemic than some weeks ago, they could again be overwhelmed should cases surge in August, particularly if citizens ignore precautions during Eidul Azha celebrations and the month of Muharram, when large mourning processions are held. The virus has also spread to rural regions, where the health infrastructure is even weaker.

The federal government’s centralised decision-making has often made things worse. It has refused to share authority, even though the constitution grants the provinces responsibility for the health sector. Islamabad’s pandemic policies, devised by the top political and military leadership, have prevailed over provincial preferences, with court rulings strengthening centralised control. The Pakistan Peoples Party’s government in Sindh, the sole opposition-led province, has promoted rigorous restrictions, for instance, but has been unable to implement them in the face of Islamabad’s resistance. The federal government has also been reluctant to work with parliament or main opposition parties to forge a united response. The acrimony is rooted in contested mid-2018 elections, though the opposition has repeatedly offered to assist the government in containing the pandemic.

The public health crisis and economic downturn could be devastating, particularly if people feel it is mismanaged. Anger at the government and social tensions will mount if citizens sense that the government is not adequately looking after their health and wellbeing. In the past, militant groups have exploited such opportunities to gain local support.

While COVID-19 leaves Pakistan’s government few good options, some steps could minimise harm to lives and livelihoods. The prime minister’s fears about the toll of lockdowns are well justified. Yet the economy is unlikely to start moving unless the authorities can keep the virus at bay. Adapting the smart lockdown strategy might avoid the pain of a prolonged lockdown while still saving lives. This could mean allowing provinces, if medical experts so advise, to lock down entire cities and urban districts for short periods, instead of limiting them to partial closures. More broadly, the government should guide the country’s response but give provinces leeway to devise policies tailored to local needs. Bolstering the provinces’ health capacity – particularly testing – should remain a top priority. Emergency assistance to families that fall under the poverty line and unemployed workers remains critical. Prime Minister Imran Khan’s – and the country’s – interests would also be best served by working with the opposition to forge consensus on managing the consequences of an unprecedented and potentially destabilising health crisis.

II. Responding to the Pandemic

A. early missteps.

As happened in many other countries, early missteps overshadowed the Pakistan Tehreek-e-Insaf government’s response. In February, the government refused to repatriate hundreds of Pakistani students in Wuhan, China, fearing they would spread the virus. In itself, the decision appears to have been sensible, though perhaps the government could have brought them home but quarantined them. Yet despite its caution with citizens in Wuhan, it failed to properly screen inbound travellers, many of whom carried the virus. [fn] International flights continued to operate until 21 March. Hide Footnote  The first confirmed COVID-19 case in Pakistan was that of a Karachi student returning from pilgrimage in Iran on 26 February. Shia pilgrims coming home from Iran, at the time the region’s worst-hit country, formed the first major cluster of imported infections. The government quarantined hundreds of pilgrims in overcrowded, unhygienic conditions near the Iranian border but then allowed them to leave for their home provinces without adequate testing or isolation, spreading the virus throughout the country. [fn] Between 28 February and 15 April, 7,000 pilgrims returned from Iran, 6,800 through the Taftan border crossing, where many were initially quarantined. “7,000 pilgrims have returned from Iran since February: FO”, Dawn, 19 April 2020. Hide Footnote

The first major cluster of locally transmitted infections occurred when the ruling party’s Punjab government delayed a decision to cancel the Sunni proselytising group Tableeghi Jamaat’s major annual congregation ( ijtema ), due to take place for five days from 11 March. The organisers ultimately cancelled the ijtema , but only on 12 March, by which time an estimated 100,000 believers, including around 3,000 foreigners, had already set up camp together in close quarters. Had the Punjab government given “clear instructions”, a Tableeghi Jamaat follower said, “the event would not have happened”. [fn] The Punjab police put numbers at 70,000 to 80,000. Other estimates were as high as 250,000. Asif Chaudhry, “Tableeghi Jamaat in hot water in Pakistan too for Covid-19 spread”, Dawn , 8 April 2020. Hide Footnote  After its cancellation, most participants left, but a few hundred stayed on at the organisation’s Raiwind headquarters. They, too, were allowed to leave for their home provinces without being tested or isolated; Tableeghi Jamaat members also went on preaching missions throughout the country. Large clusters of virus transmission in at least two provinces, Punjab and Sindh, have been traced to Tableeghi Jamaat members who had participated in the Raiwind ijtema . [fn] “Limiting the spread,” Dawn, 2 April 2020; “27 per cent of Pakistan’s Covid-19 cases linked to Raiwind Ijtema : report”, The Express Tribune , 23 April 2020. Hide Footnote

B. Pandemic Policy in Pakistan’s Fractured Polity

The Pakistan Tehreek-e-Insaf government was slow to respond as the pandemic spread. The first cabinet meeting devoted to the subject was held on 13 March, weeks after the confirmed case in Karachi. [fn] “Pakistan closes western borders, bans public gatherings as coronavirus cases rise to 28”, Dawn , 13 March 2020. Hide Footnote  The federal government’s approach was then shaped by an adversarial relationship with the opposition and an overreliance on the military’s support.

At a time when political consensus was most needed in forging a national response to the pandemic, the federal government’s relationship with the two largest opposition parties, Nawaz Sharif’s Pakistan Muslim League and Bilawal Bhutto Zardari’s Pakistan Peoples Party, was strained. The antagonism had its roots in the contested July 2018 elections. Both main opposition parties attributed Imran Khan’s victory to manipulation. After forming a government with a razor-thin majority, and entering into coalitions with smaller parties, Imran Khan’s survival tactics have been twofold: to consolidate ties with the country’s powerful military, and to weaken opposition parties by targeting their top leaders, including by charging and imprisoning them on corruption allegations.

By mid-March, as cases of local transmission began to mount, particularly in large, densely populated cities such as Karachi, Lahore and Peshawar, both opposition parties offered to cooperate to counter the pandemic. The federal government, however, chose to sideline parliament, where the opposition had a strong presence. [fn] Because of the political discord, a special pandemic-related parliamentary committee has been dysfunctional since it was set up on 26 March. Composed of both the federal parliament’s houses, with ruling and opposition party representatives, it was meant to review, monitor and oversee issues related to COVID-19 and its impact on the economy. Hide Footnote  Tensions over the direction of pandemic policy also increased between the centre and Sindh (of which Karachi is the capital), the sole opposition-led province.

On 23 March, Sindh’s Pakistan Peoples Party government was the first to impose a province-wide lockdown. Warning of the health dangers, the provincial government urged the centre to devise a national strategy, including through robust shutdown measures. Addressing the nation on 23 March, Prime Minister Khan, who himself holds the federal health portfolio, initially ruled out a countrywide closure, saying it would adversely affect the poor and working class. [fn] “PM rules out lockdown, disapproves of panic buying”, Dawn , 23 March 2020. Hide Footnote  Calling for national consensus and coordinated efforts before the health crisis turned into “a catastrophe”, Pakistan Peoples Party leader Bhutto Zardari responded, “If we are a poor country, we need to lock down more quickly”. [fn] “If we really care about the poor”, he said, “we need to move faster because the poor are more threatened”. “Bilawal wonders at PM decision of not ordering countrywide lockdown”, Dawn, 23 March 2020. Hide Footnote  The military weighed in, supporting a lockdown and deploying troops countrywide to assist civilian administrations in enforcing it. Hours after the prime minister’s address, the federal government reversed course, agreeing to impose a nationwide shutdown, which it subsequently extended until 31 May.

The initial responses of Pakistan’s four provincial governments varied. Sindh was quick in imposing stringent restrictions on non-essential businesses and public movement. Though hindered by limited resources, it also began to aggressively test people and isolate positive cases. [fn] Editorial, “Sindh leads the way”, Dawn , 28 March 2020; Talat Masood, “Leadership is facing its real test”, The Express Tribune , 2 April 2020. Hide Footnote  The three ruling party-controlled provinces, Balochistan, Khyber Pakhtunkhwa and Punjab, also imposed lockdowns. Yet, apparently guided by the prime minister’s aversion to these measures, they opted for looser restrictions, particularly in Punjab, which soon allowed several types of businesses to reopen.

Tense relations between the government and its rivals also hindered coordination between the capital and opposition-held Sindh and among provinces themselves. The Sindh government held the federal leadership responsible for hampering its response. It argues that Islamabad’s support was insufficient, whether in assisting provincial safety protection schemes or providing pandemic-related medical equipment, which, according to the Sindh government, was available but not equitably distributed. [fn] Amir Wasim, “Barbs fly in NA over fight against Covid-19”, Dawn , 12 May 2020; “PPP calls federal govt “incompetent’, blames it for virus spread”, The News , 2 May 2020. Hide Footnote  Inter-provincial coordination was also poor, echoing friction between Khan and his opponents. [fn] Maleeha Lodhi, “Fault lines in focus”, Dawn, 11 May 2020. Dr Lodhi was Pakistan’s permanent representative to the UN (February 2015-October 2019), and twice appointed Pakistan’s ambassador to the U.S. See also “Sindh’s Murtaza Wahab says federal govt ‘didn’t take lead’ over coronavirus pandemic”, The News, 29 March 2020; “Sindh refutes centre’s claim of providing medical equipment”, Dawn , 17 May 2020. Hide Footnote  The three ruling party-held provinces seemingly took their lead from Islamabad’s aversion to working with Sindh. [fn] Fizza Batool, “Pakistan’s Covid-19 political divide”, South Asian Voices , 12 May 2020. Hide Footnote

Much decision-making related to the pandemic has taken place in the federal capital. The main bodies responsible, set up in mid-March, reflect the government and military leadership’s preference for a centralised approach. On 13 March, the National Security Committee, the apex civil-military body, set up a National Coordination Committee for COVID-19, chaired by the prime minister and including Army Chief Qamar Javed Bajwa, the four provincial chief ministers and senior military officers. The National Command and Operation Centre, which sends the committee recommendations on pandemic policy, is headed by the federal minister for planning and development and includes relevant federal and provincial ministers and also several senior military officers.

The stated objective of setting up these two bodies was to bring the federal and provincial governments and military leadership together. [fn] The National Coordination Committee includes the director general of Inter-Services Intelligence directorate, the military’s premier intelligence agency, and the director general of military operations. The command and cooperation centre, according to a military spokesperson, was formed “to collect, analyse and collate information received from the provinces and forward recommendations” to the coordination committee so that it could “make timely decisions”. “Can’t afford ‘indefinite’ lockdown: DG ISPR”, The Express Tribune , 4 April 2020; “Corona has economic, psycho-social impacts: General Qamar Javed Bajwa”, The News , 23 April 2020. See also Zeeshan Ahmed, “A look inside Pakistan’s Covid-19 response”, The Express Tribune, 2 May 2020. Hide Footnote  In principle, responsibility for the health sector lies with the provinces, not the capital. [fn] The 2010 constitutional amendment, which restored federal parliamentary democracy after a decade of military rule, gives provinces this mandate. Hide Footnote  In practice, however, the top political and military leadership in the centre controls pandemic policy, often overriding provincial concerns, not just in opposition-led Sindh but also in the three ruling party-led federal units.

On 14 April, Prime Minister Khan extended the nationwide lockdown until 30 April but also relaxed restrictions. Several non-essential industries, including construction, reopened. Khan said there was “98 per cent consensus among all provinces and the centre on the reopening of some sectors”. [fn] “PM Imran Khan extends lockdown for two weeks”, The Express Tribune, 14 April 2020. Hide Footnote  Yet the Sindh government, disagreeing, opted to retain stricter measures for another two weeks. While acknowledging that it was constitutionally empowered to so, the federal minister in charge of pandemic response warned the provincial government against resisting Islamabad’s directives. [fn] “PM extends lockdown for two weeks”, The Express Tribune , 15 April 2020; “Centre assails Sindh govt over ‘stricter’ lockdown”, Dawn , 16 April 2020. Hide Footnote  Judicial intervention then strengthened the centre’s control over pandemic policy. In a suo moto (on its own volition) hearing on the virus crisis in mid-April, the Supreme Court chief justice called for a uniform policy, warning Sindh not to close businesses and services that generate revenue for the federation. The Sindh government then gave in to the centre’s wishes. [fn] “Sindh can’t close entities paying taxes to centre: SC”, The Express Tribune , 4 May 2020. Hide Footnote

C. Mixed Messaging and the Power of the Pulpit

The mid-April decision to ease the lockdown and the federal government’s mixed messaging about the pandemic left the public confused about its gravity. Early in the crisis, in a televised address on 17 March, Prime Minister Khan had downplayed health risks. “There is no reason to worry”, he said, since 90 per cent of the infected would have mild flu-type symptoms and 97 per cent would recover fully. [fn] “PM Imran tells nation to prepare for a coronavirus epidemic, rules out lockdown”, Dawn, 17 March 2020. See also Khurram Hussain, “Addressing the confusion”, Dawn , 2 April 2020. Hide Footnote  A mid-April decision to reopen mosques for communal prayers further muddled the state’s message.

When the nationwide lockdown was first imposed, provincial governments barred mosques from holding communal prayers. Mosques remained open but only five mosque administrators could participate in prayers. The police were tasked with enforcing the restrictions, which were largely respected in major cities. When clerics violated the curbs in Karachi, for example, police temporarily detained most offenders; charges were lodged against others for inciting violence against police officers. [fn] “Prayer leader, six others sent to jail on judicial remand in Sindh”, The Express Tribune , 5 April 2020. Hide Footnote  As a result, most mosques in Sindh’s cities complied with the health restrictions. [fn] “Has the federal govt erred by not closing mosques in Ramadan?”, Pakistan Today , 30 April 2020. Hide Footnote

In contrast, Islamabad’s police registered cases but made no arrests when Lal (Red) mosque’s hardline clerics openly violated restrictions. Clerical leader Abdul Aziz released footage of large congregations attending Friday prayers. [fn] Kalbe Ali, “More than 50 clerics warn govt not to further restrictions on prayer congregations”, Dawn , 14 April 2020. Hide Footnote  When the police tried to barricade the mosque’s entrance, female madrasa students blocked the road. [fn] In early June, the federal government reportedly reached agreement with Abdul Aziz, mediated by the leader of a banned sectarian group; the police were to remove blockades in return for Aziz’s commitment to vacate the mosque. “Capital administration, former Lal Masjid cleric reach agreement”, Dawn , 3 June 2020. Hide Footnote  The Khan government might have hesitated in taking action against the Lal Masjid clerics, fearing a repeat of the bloody July 2007 standoff, when a military operation against heavily armed jihadists in the mosque left 100 militants and eleven soldiers dead. [fn] For details of the Lal Masjid operation, see Crisis Group Asia Report N°164, Pakistan: The Militant Jihadi Challenge , 11 March 2009. Hide Footnote  Yet in refraining from taking action, it risked creating a major virus cluster in both the federal capital and its twin city, Rawalpindi.

On 18 April, without consulting provincial governments, President Arif Alvi agreed with major religious leaders to reopen mosques nationwide for communal, including taraweeh (special Ramadan), prayers – but under conditions. [fn] Several senior clerics had warned the federal government against retaining restrictions on mosques. “More than 50 clerics warn govt not to further restrictions on prayer congregations”, Dawn , 14 April 2020. Hide Footnote  The agreement specified safety and health precautions, including social distancing, and tasked mosque administrations with enforcing them. To violate the measures, the president said, “would be like a sin because all ulema and mashaikh (religious scholars and spiritual leaders) have agreed” to them. [fn] “PTI govt, Ulema agree on SOPs for Ramazan amid coronavirus outbreak”, The Express Tribune , 19 April 2020. Hide Footnote  Justifying the decision, Prime Minister Khan said he was heeding popular demand. “Pakistan is an independent nation”, he said. “Ramadan is a month of worship, and people want to go to mosques”. His government “could not forcibly tell them not to do so”. [fn] “‘We are an independent nation’: PM Khan responds to questions over keeping mosques open”, Dawn , 21 April 2020. On 21 April, prominent doctors called on the government and religious leaders to reconsider their agreement, warning that removing curbs on communal prayers would create viral clusters and “unwanted loss of lives”. “Failure to close mosques, control virus in Pakistan may be bad for entire Muslim ummah: doctors”, The News , 21 April 2020. Hide Footnote

Yet many clerics have flouted the agreement’s terms. During Ramadan, when mosque attendance is at its highest, clerics made little effort to enforce the protocols. [fn] A survey of mosques in Punjab and the federal capital during Ramadan found that 85 per cent had violated health and safety protocols. Kamila Hayat, “Duel till death”, The News , 30 April 2020; “Violations of SOPs for mosques aggravates virus situation in KP”, Dawn , 6 May 2020. Hide Footnote  Thousands prayed in packed mosques, ignoring health measures and creating new hot-spots of viral infection. [fn] “Violations of SOPs for mosques aggravates situation in KP”, Dawn, 6 May 2020. Hide Footnote  Many clerics appear to have told worshippers to demonstrate piety by praying shoulder to shoulder, warning that the pandemic is a punishment for erring Muslims’ sins, arguing that the faithful are immune and that life and death are in God’s hands alone. [fn] In an Al Jazeera interview, Lal Masjid cleric Aziz said, “In our [religious leaders’] opinion, this is a punishment from God, and is coming because we have filled the world with sins”. Another religious leader said, “there is no coronavirus. This is just a movement to try and target religion and mosques”. Yet another insisted that the only way to get rid of the virus would be to seek forgiveness from God through prayers in mosques. “Pakistanis gather for Friday prayers defying coronavirus advisory”, Al Jazeera, 17 April 2020; “Mosques remain closed amid strict lockdown”, The Express Tribune , 4 April 2020; “‘God is with us’: Many Muslims flout the coronavirus ban in mosques”, Reuters, 13 April 2020; Kalbe Ali, “More than 50 clerics warn govt not to further restrictions on prayer congregations”, Dawn , 14 April 2020. Hide Footnote  As a result, many who regularly attend mosques either believe they will not contract the virus or that prayer will protect them. [fn] A mid-April survey found that 82 per cent believed that ablution for prayers would prevent infection and 87 per cent that communal prayers could not cause contagion. “Survey shows whopping majority thinks inhaling steam, ablution wards off COVID-19”, The News , 12 April 2020. Hide Footnote  Many also chose not to get tested or treated due to religious and social stigma attached to the disease. [fn] Crisis Group telephone interviews, health professionals, Karachi, Islamabad, May 2020. Hide Footnote

III. The Economy, Health Policy and Social Support

On 9 May, after extending relatively weak pandemic-related restrictions for two weeks, the federal government ended the lockdown. Prime Minister Khan insisted that the decision was taken with the provinces’ consensus, but Sindh’s chief minister said Islamabad imposed its will. [fn] “Sindh CM didn’t announce lifting lockdown from Monday, Bilawal”, The Express Tribune , 9 May 2020; Syed Irfan Raza, “Record Covid-19 cases reported in single day”, Dawn , 9 May 2020. Hide Footnote  The Punjab and Balochistan governments, held by the ruling party, also warned against lifting restrictions. [fn] Raza, “Record Covid-19 cases reported in single day”; “Relaxed curbs will mean 1.1.m cases by July”, The Express Tribune , 9 May 2020. Hide Footnote  The judiciary again weighed in. On 19 May, during the coronavirus suo moto case hearings, the Supreme Court noted that provinces were constitutionally bound to follow Islamabad’s directives. [fn] In a June interview, Sindh’s spokesperson noted, “the court said provinces have to follow the lead and advice of the centre. We never stood a chance [after that]”. Dawn TV, 10 June 2020; “Provinces are bound to follow Centre’s directives: SC”, The Express Tribune , 19 May 2020. Hide Footnote

Though the federal government said it would lift the lockdown in phases, by mid-June the country was almost fully open for business. Schools remained closed but all markets and shopping centres were operating and restrictions on most non-essential businesses had been removed. Borders with Iran and Afghanistan were reopened, domestic and international flights resumed, and several train services started up again, as did local public transport. Punjab reopened shrines that traditionally attract large numbers.

Prime Minister Khan’s justifications for lifting the lockdown were twofold: the burden on the poor and working class, and the adverse impact on the national economy. Announcing the National Coordination Committee’s decision to cancel the closures on 7 May, he said, “We are doing it because people are facing extreme difficulties. Small business owners, daily wage earners and labourers are suffering. We fear that small and medium-sized industries might vanish completely if we don’t lift the lockdown”. [fn] “Govt to end lockdown from 9th in phases”, The Express Tribune, 8 May 2020. Hide Footnote  A week earlier, preparing the ground for the announcement, the federal minister heading the National Command and Operation Centre said the government’s revenues would otherwise fall by 30-35 per cent. [fn] “Lockdown to be further eased, says PM Khan”, Dawn, 1 May 2020. Hide Footnote

The pandemic has seriously compounded Pakistan’s already grave economic challenges. Pakistan’s economy was in dire straits even before COVID-19. Since the Khan government assumed office, large-scale manufacturing has declined, exports have fallen, the budget deficit has widened and unemployment has increased. [fn] Sharoo Malik, “Taking stock: The PTI government’s economic performance in its first year”, South Asian Voices, 8 September 2019; “Pakistan premier’s first year: economic hit and miss”, Dawn, 19 August 2020; Hina Ayra, “Pakistan’s economic options during the coronavirus crisis”, The Express Tribune , 3 April 2020. See also editorial, “GDP growth”, The News , 18 May 2020. Hide Footnote  A former finance minister and financial expert had estimated economic growth in the Khan’s government’s first year at 1.9 per cent, the lowest in a decade. [fn] “Hafiz Pasha says GDP growth is 1.9 per cent”, The News , 8 February 2020. Dr Hafiz Pasha, the former finance minister, is now chair of the Panel of Economists, an independent body advising the government. Hide Footnote  Now, exports to traditional markets – Europe, the U.S., China and the Middle East – are fast declining. [fn] Syed Haris Ahmed, “With lockdowns everywhere, export is a difficult job”, The Express Tribune, 6 April 2020; “Pakistan’s deficit and poverty rate to soar due to coronavirus, govt estimates”, Reuters, 14 May 2020. Hide Footnote  Remittances, a vital source of foreign exchange, are likely to shrink as thousands of workers in the Gulf come home. The government estimates that the gross domestic product will contract by 0.38 per cent for the fiscal year 2019-2020. The World Bank has forecast even sharper drops of 2.6 per cent for 2019-2020 and 0.2 per cent for 2020-2021. [fn] The economy has contracted for the first time since 1951-1952. Pakistan Economic Survey 2019-20 ; “Global Economic Prospects ”, The World Bank, June 2020. Hide Footnote

If the government’s goal in lifting the lockdown was to get the economy moving, little suggests that is happening, even as numbers of new cases mount. Indeed, it has become ever clearer that economic growth depends on curbing the virus. On 22 April, days after the lockdown was first eased, the World Health Organisation’s director general had warned, “Without effective interventions [in Pakistan], there could be an estimated 200K+ cases by mid-July. The impact on the economy could be devastating, doubling the number of people living in poverty”. [fn] “WHO, PMA advise for total lockdown”, The News, 24 April 2020. Hide Footnote  Four months on, signs of economic recovery are still few.

The federal government has provided emergency assistance to families in need, including food subsidies and support, but for many this aid is barely enough. The Ehsaas emergency cash program (the renamed Benazir Income Support Program) provides financial assistance to an estimated twelve million families that fall under the poverty line. [fn] Set up in mid-2008, the federally funded Benazir Income Support Program, the country’s largest social safety net, provides cash assistance exclusively through women to economically vulnerable families. Hide Footnote  Islamabad began the scheme on 9 April and extended it the following month to provide a similar amount to four million unemployed workers. [fn] “PM launches cash disbursal program for workers today”, Dawn , 18 May 2020. Hide Footnote  Yet the lump sum cash transfer of approximately $75 to cover four months of expenses hardly covers food costs.

Such support could well be critical for months. According to Prime Minister Khan, the cash disbursement program can only be a temporary solution, which is why the lockdown was lifted. “There’s no way the government can give out handouts to feed people for that long”. [fn] “Millions would have starved if lockdown wasn’t lifted: PM Khan”, Dawn TV, 21 May 2020. Hide Footnote  Yet with the pandemic continuing to hinder any economic recovery, the need for state assistance appears likely to increase further. A prominent public health expert and demographer noted: “There is no choice but to provide the essentials like food, water and health care for the poorest 20 per cent of the population for the next few months. ... [t]he counterfactual is skyrocketing poverty, malnutrition and deaths of key household members that will be difficult to repair financially and emotionally”. [fn] Zeba Sattar, “Lives not worth saving”, Dawn , 13 June 2020. As Pakistan country director of the Population Council, Dr Sattar evaluates health delivery services. According to the World Food Program , 39.6 per cent of the population faces food insecurity, and Pakistan has the second highest rate of malnutrition in South Asia. Hide Footnote

At the same time, the government’s financial resources are strained, though foreign aid should help. Donors have earmarked additional assistance to help Pakistan cope with the pandemic’s economic impact, including through social protection programs for families in need. The government looks set to receive billions of dollars in pandemic-related aid. [fn] The government will likely receive $1.5 to $2 billion in temporary debt relief from G20 member counties; the International Monetary Fund allocated $1.4 billion through its Rapid Financing Instrument, to mitigate the economic impact of the pandemic; the World Bank restored Pakistan’s budgetary support and granted a $500 million loan for pandemic-related health care and social safety nets; the Asian Development Bank approved a $500 million loan for the government’s health and economic response, including social protection for the poor. Bilateral donors, such as Germany, have also extended assistance, with Berlin providing 0.5 million euros to help Pakistan overcome the pandemic’s socio-economic impact at the local level. “Germany backs Pakistan’s efforts to mitigate socio-economic impact of Covid-19”, Dawn, 27 July 2020; “Pakistan to receive $500m loan from ADB to help fight coronavirus, ‘protect poor’”, The News, 10 June 2020; “WB okays $500m loan to help government fight Covid-19”, Dawn , 23 May 2020; “Pakistan wins $1.4b IMF emergency loan”, The Express Tribune , 17 April 2020; Arsalaan Asif Soomro, “Can Pakistan’s economy endure the ramifications of COVID-19?”, The Express Tribune, 15 April 2020. Hide Footnote

The dire economic situation risks playing into militants’ hands, particularly if social support measures fall short. As unemployment rises further and more citizens fall under the poverty line, such groups could exploit the ensuing social discord. If the state fails to deliver, they could have new opportunities to win recruits by tapping economic desperation and social grievances or extending assistance through existing or renamed charities, as they have in the past. [fn] Militant groups have in the past enhanced their local appeal by providing food and other assistance through their charity wings, including after the 2005 earthquake in Pakistan and Pakistan-administered Kashmir. See Crisis Group Asia Briefing N°46, Pakistan: Political Impact of the Earthquake , 15 March 2006. Hide Footnote

IV. Health Systems in a Pandemic

Pakistan’s under-funded health care system is ill equipped to deal with an unprecedented public health emergency. [fn] There are around six hospital beds, 9.8 doctors and five nurses per 100,000 population in Pakistan. Health expenditure is among the lowest in the world, estimated by the World Health Organisation at 2.9 per cent of GDP. “Time to step up”, The News , 23 March 2020. Hide Footnote  Medical professionals have repeatedly called for a stringent nationwide lockdown until transmission rates decline. But the government, concerned about the economic costs, rejects their advice. In some cases, ruling-party leaders have even dismissed concerns as partisan. When positive COVID-19 cases increased by 40 per cent nationwide soon after the lockdown was eased in mid-April, Karachi-based health experts and doctors called for stricter restrictions, warning that major hospitals in the city were overstretched. [fn] “Covid-19 cases up by 40% in five days, doctors”, The Express Tribune , 23 April 2020; “WHO, PMA advise for total lockdown”, op. cit. Hide Footnote  A ruling-party leader accused them of criticising the federal government on behalf of the Pakistan Peoples Party opposition. [fn] “Gill accuses Sindh govt of politicising corona situation thru doctors”, The News , 24 April 2020. Shahbaz Gill has since, in mid-May, been appointed the prime minister’s special assistant on political communication. Also Iftikhar A. Khan, “PPP asks centre to stop playing ‘pandemic politics’”, Dawn , 25 April 2020. Hide Footnote  Professional bodies of doctors countrywide have issued similar calls for a nationwide closure to contain the disease’s spread both before 9 May and afterward. [fn] “Doctors demand strict lockdown, urge religious scholars to review decision to open mosques”, Dawn , 22 April 2020; Amer Malik, “Health care in a fix”, The News, 31 May 2020. Hide Footnote

While the decision on when to lift the lockdown would always involve difficult trade-offs, the government appears to have moved too early. Retaining a nationwide lockdown indefinitely would not have been feasible for economic reasons and due to public fatigue. As Prime Minister Khan says, the lockdown took a heavy toll on impoverished Pakistanis, who survive at subsistence level and need handouts if they cannot leave their homes to work. A protracted nationwide lockdown would have risked fuelling public anger as much as the health emergency. Yet reopening the economy and the country as early as was done, without adequate testing, tracing, isolating and treating the infected, led to a sharp spike in cases. By 9 May, when the lockdown was lifted, the total number of cases was around 29,000 and the death toll was 637. About six weeks later, the total number of cases were more than 175,000; the death toll stood at over 3,000. [fn] “Sindh reports highest single day increase nationwide; nationwide tally soars to 28,818”, The Express Tribune , 9 May 2020; “Pakistan crosses 3,000 deaths due to COVID-19”, Newsweek Pakistan, 18 June 2020; “Pakistan reports 4,471 cases of Covid-19 in a day”, The Nation , 22 June 2020. Hide Footnote

In early June, the World Health Organisation’s Pakistan country head recommended imposing targeted and intermittent two-week-on, two-week-off lockdowns. His letter to the Punjab health minister noted that the country met none of the prerequisites for fully lifting restrictions, including containing disease transmission, detecting, testing, isolating and treating all cases, minimising hot-spots and ensuring preventive measures in workplaces and other public spaces. [fn] “WHO recommends ‘intermittent, targeted’ lockdowns in Pakistan”, The Express Tribune, 9 June 2020. Hide Footnote  Health experts were quick to support his recommendation. But the prime minister’s health adviser said the WHO had assessed Pakistan’s situation through a “health lens” and that the government has “to make tough policy choices to strike a balance between lives and livelihoods”. [fn] “WHO says Pakistan meets no pre-requisite for easing restrictions, recommends ‘intermittent lockdown’”, Dawn, 9 June 2020; “Corona killing four an hour in Pakistan”, The News, 11 June 2020. Hide Footnote

Instead, the federal government has opted for what it calls “smart lockdowns”, a policy it adopted when easing pandemic-related restrictions in mid-April. Its limited lockdowns differ from those recommended by the WHO in that they apply only to specific localities within cities or rural districts where positive cases are high. The government eased or removed them altogether in low-risk areas. [fn] Inter-Services Intelligence, the military’s main intelligence arm, has been tasked with tracing infected persons and their contacts through geo-fencing and phone monitoring systems that it uses for counter-terrorism purposes. Ramsha Jahangir, “Over 5,000 people at risk of contracting Covid-19 identified by track system”, Dawn , 2 May 2020. Hide Footnote  In mid-June, provincial governments imposed two-week lockdowns in areas of cities such as Karachi, Lahore and Peshawar. [fn] On 15 June, the National Command and Operation Centre identified virus clusters in twenty cities across the country. According to a press release from his office, Prime Minister Khan had directed the provincial governments to impose smart lockdowns “in sensitive areas keeping in view ground realities to maintain a balance between economic activities and preventive measures”. Syed Irfan Raza, “PM satisfied with virus testing kits, PPE availability”, Dawn, 16 June 2020. Hide Footnote  The government argues that such limited lockdowns can contain virus spread without economic hardship.

By 2 August, Pakistan had around 280,200 registered cases and close to 6,000 deaths, ranking thirteenth among COVID-19 affected countries globally (in terms of total cases). [fn] See Pakistan’s official COVID-19 website or the Worldometers website for numbers. The death toll is likely under-counted since many families, fearing the religious and social stigma of the disease, do not report infections or seek treatment. The Khyber Pakhtunkhwa government, for instance, is investigating declining mortality figures, to check if patients are dying unrecorded at home. “Govt probing causes of decline in Covid-19 deaths”, Dawn , 23 July 2020. Hide Footnote  According to official statistics, the daily number of confirmed cases has declined considerably since mid-July. The government attributes the reduction to its smart lockdowns. [fn] The prime minister’s health adviser said the government had managed to contain the pandemic through the smart lockdown strategy. “Pakistan’s preparation and response to the coronavirus outbreak has been one of the best in the world”. “Over 204,000 recover from disease as curve flattens”, The Express Tribune , 20 July 2020. Hide Footnote  Yet reduced testing may also partly explain it: official data shows daily nationwide testing rates dropping from on average around 28,500 in June to fewer than 22,00o in July. [fn] In June, the WHO had recommended that Pakistan increased daily testing capacity to 50,000. Daily test numbers, however, fell from the end of June. By 2 August, according to the Worldometers website, Pakistan had conducted 2,010,170 tests for around 220 million citizens: 9,086 per one million population. See also “Pakistan: Situation Report (as of 10 June 2020)”, UN Office for the Coordination of Humanitarian Affairs. Hide Footnote

The smart lockdown’s “track, trace and quarantine” strategy, which involves tracing and isolating virus carriers and their contacts and placing viral hot-spots under quarantine, is hampered by poor data and low testing rates. [fn] Crisis Group interviews, doctors, Karachi, July 2020. Hide Footnote  In June, the minister overseeing the pandemic response had said that authorities would increase daily testing capacity to 100,000 by July. [fn] “Just in a month: Pakistan faced 242pc surge in deaths”, The News , 15 June 2020. Hide Footnote  According to the National Command Operation Centre, testing capacity had increased to over 70,000 by early July. [fn] Calling for increased testing, a doctors’ forum said that the government’s figures of confirmed cases are “not representative of the actual ground situation”, “Doctors’ forum stresses need to enhance Covid-19 testing in Pakistan”, Dawn , 12 July 2020; “Covid-19: Data shows Pakistan utilising only a third of its testing capacity”, The News , 8 July 2020. Hide Footnote  Yet less than one third of that capacity is now being used. [fn] Observers offer various reasons for the decline in testing: international travellers are no longer tested on arrival; groups that were previously targeted, such as Tableeghi Jamaat, journalists and government officials, are no longer tested systematically; tests’ costs mean they are used only for patients with serious symptoms; and, with numbers declining, fewer tests are necessary. Hide Footnote  With the virus appearing in many localities in densely populated cities, limited lockdowns of a few blocks of a city or a part of a rural district appear unlikely to contain it. A Pakistani expert on viral diseases said, “Incomplete lockdowns mean the virus has a chance of finding new hosts”. [fn] Tufail Ahmed, “Containing pandemic: Don’t bother with partial lockdowns, says expert”, The Express Tribune , 16 June 2020. Hide Footnote

The forthcoming religious holidays threaten another uptick. The lifting of nationwide restrictions during Ramadan in June and for Eidul Fitr contributed to the first surge of infections as massive crowds shopped in markets and large congregations prayed in mosques. The government and doctors fear the virus could once again peak should the public disregard safety measures in August during Eidul Azha festivities and in Muharram, when large mourning processions are held. [fn] Prime Minister Khan said, “if we are careless on Eidul Azha, the virus could spread again and there could be a fresh spike of infections”. “PM warns of virus spike of SOPs violated on Eid”, Dawn , 10 July 2020. Hide Footnote  Spiralling numbers of cases could once again overwhelm hospitals and clinics. With case numbers increasing substantially in smaller cities and rural regions, their weaker health facilities could soon be overrun.

V. Conclusion

Chairing a meeting of the National Coordination Council on 1 June, Prime Minister Khan said, “a lockdown isn’t a solution or treatment. … Nothing can be done about it. The virus will spread, and our death toll will also rise” until a vaccine is found. He added, “If we have to live successfully with the virus, it is the responsibility of the people. If they take precautionary measures, we can tackle the virus and live with it”. [fn] Khan also decided to further ease the few remaining restrictions, including on domestic tourism. “Pakistan to ease lockdown, open more businesses amid surging COVID-19 infections”, The News , 1 June 2020; “PM Khan bats for unlocking economy, eases coronavirus lockdown”, The Express Tribune , 2 June 2020. Hide Footnote  Placing the onus of preventing contagion on citizens also appears at the heart of a new strategy, “Living with the Pandemic”, discussed by the Command and Operation Centre a day earlier. [fn] “88 deaths, 3,039 new cases in a single day: Provinces differ over smart lockdown”, The News , 1 June 2020; “NCOC mulls over ‘living with the pandemic strategy’ to cope with coronavirus”, The News, 30 May 2020. Hide Footnote

Mixed and confused signalling by Prime Minister Khan and his top advisers early in the crisis mean that people often now ignore their calls to observe social distancing and other health guidelines. Many still believe that the pandemic has ended, and largely brush off calls for responsible public behaviour. Public health specialists also warn that “leaving people to determine the rules of restoring normality could prove fatal if growth in cases and deaths continues at average rates or may even increase further”. [fn] “Easing Lockdown in Pakistan: Inevitable but Potentially Catastrophic”, Institute of Public Health, Jinnah Sindh Medical University, May 2020. Hide Footnote

A rethink is urgently needed. Federal policy should be based on the best available medical advice, even while factoring in social and economic costs. The government should continue to guide the provinces on pandemic policy, including by helping them shore up health facilities and making preventive measures, such as enforcing the use of face masks outdoors. Yet Islamabad should also allow provincial authorities to devise tailored strategies, guided by medical experts, as they confront new challenges. Not only is health a provincial responsibility, but provincial leaders are better placed to adapt to local needs. Both federal and provincial authorities should also prioritise funding for the health sector.

Islamabad could consider revising its smart lockdown strategy. If deemed necessary, and based on medical advice, provinces should be allowed to shut down entire cities and rural districts with high infection rates for limited periods to interrupt virus transmission. In areas where the virus transmission rate is lower, they should enhance testing, contact tracing and treating the infected. Lockdowns along these lines should be better able to contain virus spread without too onerous a burden on the economy.

Efforts to build the capacity of health care facilities to prevent a repeat of the crisis in June, when cases surged, should continue. In June, intensive care units and beds in major cities like Karachi, Lahore and Peshawar reached or neared capacity. [fn] By early June, critical care wards for COVID-19 patients in some of Karachi’s major government and private hospitals were full to capacity. Hospitals in Lahore were also under strain. Crisis Group telephone interviews, doctors, nurses, Karachi, Lahore, June 2020. Hide Footnote  The provinces have since bolstered health facilities for COVID-related cases, including with federal assistance. [fn] “NDMA reaches target of 2,000 oxygenated beds in hospitals across Pakistan”, The Express Tribune , 22 July; “Sindh has 253 million beds for Covid-19 patients”, The Express Tribune, 14 July 2020. Hide Footnote  Pressures on hospitals have also eased since patients with moderate symptoms are now isolated at home. Yet another sharp surge of infections could once again overwhelm that capacity.

Lastly, instead of bypassing parliament, the federal government should work with the opposition. The parliament should play a more active role, particularly with regard to fiscal and other assistance for the most vulnerable sections of the population. The federal government’s continued targeting of top opposition leaders, including through the National Accountability Bureau, is particularly unhelpful. The Khan government itself would benefit from mending fences with its rivals. The military leadership might be an equal, if not dominant, partner in the pandemic response. Yet citizens will hold the elected leadership accountable if the pandemic response falters. Sharing responsibility with opposition leaders for what are difficult and contentious decisions would not only benefit Pakistan’s body politic but also make sense for the premier himself. The alternative is that COVID-19 leaves a weakened federal government even more reliant on the military to retain power.

Karachi/Islamabad/Brussels, 7 August 2020

Related Tags

More for you, raising the stakes in jammu and kashmir, pakistan: challenges of a weak democracy, subscribe to crisis group’s email updates.

Receive the best source of conflict analysis right in your inbox.

This site uses cookies. By continuing to browse the site you are agreeing to our use of cookies. Review our privacy policy for more details.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Effects of COVID-19 pandemic and lockdown on lifestyle and mental health of students: A retrospective study from Karachi, Pakistan

Affiliation.

• 1 MBBS, Department of medicine, Dow university of health sciences, Karachi, Pakistan.
• PMID: 33612842
• PMCID: PMC7883721
• DOI: 10.1016/j.amp.2021.02.004

Abstract in English, French

Introduction: Due to the COVID-19 pandemic, many countries imposed lockdowns on their citizens in an attempt to contain the disease. Pakistan is one of these countries. A government mandated lockdown can have mitigating psychological effects on young adults, out of which a large fraction is made up of students. This study aims to investigate the correlations between changes in sleep pattern, perception of time, and digital media usage. Furthermore, it explores the impact of these changes on the mental health of students of different educational levels.

Methods: This cross-sectional study was conducted via a web-based questionnaire, from March 24 to April 26, 2020. The survey was targeted at students and 251 responses were obtained. It was a 5-section long questionnaire. The first section inquired about demographics of participants. Each of the other 4 sections was devoted to changes in sleep pattern, perception of time flow, digital media usage and mental health status of students. Close-ended questions with multiple choice responses, dichotomous, interval and 4-point Likert scales were used in the construction of the survey questionnaire. Chi 2 T-tests multinomial and binary logistic regression were used as primary statistical tests. All data were analysed using Statistical Package for Social Science (SPSS) version 23.0 (IBM Corp., Armonk, NY).

Results: Out of 251 adolescents that participated in our study, the majority (70.2%) were females. The mean age of the participants was 19.40 ± 1.62 years. Two-thirds of the respondents did not have much trouble falling asleep (66.5%). The analysis found no significant association between longer sleep periods and procrastination level ( P = 0.054). Nearly three-fourths (72.9%) of our participants felt that getting through quarantine would have been more difficult if they did not have any electronic gadgets. Of these, a majority (85.8%) had a general feeling of tiredness and lacked motivation ( P = 0.023). Additionally, a large number of students (69.7%) had reported that time is seemingly moving faster. A significant relationship between increased usage of electronic items and longer sleep periods was also noted ( P = 0.005). With respect to the level of education, statistically significant values were noted for alarm use both before and after quarantine began ( P = 0.021 and P = 0.004, respectively). Further analysis showed that there was a significant difference in the median difference of time spent on social media before the outbreak (3.0 ± 32.46) and time spent on social media after the outbreak (6.0 ± 3.52) in a single day ( P = 0.000).

Conclusions: Our research has revealed that due to the lockdown imposed by the government in response to COVID-19, the sleeping patterns of the students was affected the most. Our findings show that the increase in use of social media applications led to a widespread increase in the length of sleep, worsening of sleep habits (people sleeping at much later hours than usual), and a general feeling of tiredness. A general lack of recollection regarding what day of the week it was, as well as a change in the perceived flow of time were also notable. All these findings indicate the decline in mental health of students due to the lockdown. Promoting better sleep routines, minimising the use of digital media, and encouragement of students to take up more hobbies could collectively improve the health and mood of students in self-quarantine.

Introduction: En raison de la pandémie de COVID-19, de nombreux pays ont imposé des verrouillages à leurs citoyens pour tenter de contenir la maladie. Le Pakistan est l’un de ces pays. Un verrouillage mandaté par le gouvernement peut avoir des effets psychologiques atténuants sur les jeunes adultes, dont une grande partie est composée d’étudiants. Cette étude vise à étudier les corrélations entre les changements dans les habitudes de sommeil, la perception du temps et l’utilisation des médias numériques. De plus, il explore l’impact de ces changements sur la santé mentale des élèves de différents niveaux d’éducation.

Méthodes: Cette étude transversale a été menée via un questionnaire en ligne, du 24 mars au 26 avril 2020. L’enquête visait les étudiants et 251 réponses ont été obtenues. C’était un questionnaire de 5 sections. La première section a posé des questions sur la démographie des participants. Chacune des 4 autres sections était consacrée aux changements dans les habitudes de sommeil, à la perception de l’écoulement du temps, à l’utilisation des médias numériques et à l’état de santé mentale des élèves. Des questions fermées avec des réponses à choix multiples, des échelles dichotomiques, d’intervalle et de Likert à 4 points ont été utilisées dans la construction du questionnaire d’enquête. Le chi carré, les tests T multinomiaux et la régression logistique binaire ont été utilisés comme tests statistiques primaires. Toutes les données ont été analysées en utilisant Statistical Package for Social Science (SPSS) version 23.0 (IBM Corp., Armonk, NY).

Résultats: Sur 251 adolescents qui ont participé à notre étude, la majorité (70,2 %) étaient des femmes. L’âge moyen des participants était de 19,40 ± 1,62 ans. Les deux tiers des répondants n’avaient pas beaucoup de mal à s’endormir (66,5 %). L’analyse n’a trouvé aucune association significative entre des périodes de sommeil plus longues et le niveau de procrastination ( p = 0,054). Près des trois quarts (72,9 %) de nos participants ont estimé que passer la quarantaine aurait été plus difficile s’ils n’avaient pas de gadgets électroniques. Parmi ceux-ci, une majorité (85,8 %) avait une sensation générale de fatigue et manquait de motivation ( p = 0,023). De plus, un grand nombre d’étudiants (69,7 %) ont déclaré que le temps passe apparemment plus vite. Une relation significative entre une utilisation accrue des articles électroniques et des périodes de sommeil plus longues a également été notée ( p = 0,005). En ce qui concerne le niveau d’éducation, des valeurs statistiquement significatives ont été notées pour l’utilisation des alarmes avant et après le début de la quarantaine ( p = 0,021 et p = 0,004, respectivement). Une analyse plus approfondie a montré qu’il y avait une différence significative dans la différence médiane entre le temps passé sur les réseaux sociaux avant l’épidémie (3,0 ± 32,46) et le temps passé sur les réseaux sociaux après l’épidémie (6,0 ± 3,52) en une seule journée ( p = 0,000).

Conclusions: Notre recherche a révélé qu’en raison du verrouillage imposé par le gouvernement en réponse au COVID-19, les habitudes de sommeil des étudiants étaient les plus affectées. Nos résultats montrent que l’augmentation de l’utilisation des applications de médias sociaux a conduit à une augmentation généralisée de la durée du sommeil, à une aggravation des habitudes de sommeil (personnes qui dorment beaucoup plus tard que d’habitude) et à une sensation générale de fatigue. Un manque général de souvenir du jour de la semaine, ainsi qu’un changement dans l’écoulement perçu du temps, étaient également notables. Tous ces résultats indiquent le déclin de la santé mentale des étudiants en raison du verrouillage. La promotion de meilleures habitudes de sommeil, la minimisation de l’utilisation des médias numériques et l’encouragement des étudiants à adopter plus de passe-temps pourraient collectivement améliorer la santé et l’humeur des étudiants en quarantaine.

Keywords: COVID-19; Digital media; Mental health; Perceived time flow; Sleep pattern.

© 2021 Elsevier Masson SAS. All rights reserved.

PubMed Disclaimer

Association of changes in sleep…

Association of changes in sleep pattern with mental health of students.

Association of perception of time…

Association of perception of time flow with mental health of students.

Association digital media usage with…

Association digital media usage with changes in sleep pattern.

Similar articles

• Interactions between Anxiety Levels and Life Habits Changes in General Population during the Pandemic Lockdown: Decreased Physical Activity, Falling Asleep Late and Internet Browsing about COVID-19 Are Risk Factors for Anxiety, whereas Social Media Use Is not. Smirnova D, Syunyakov T, Pavlichenko A, Bragin D, Fedotov I, Filatova V, Ignatenko Y, Kuvshinova N, Prokopenko E, Romanov D, Spikina A, Yashikhina A, Morozov P, Fountoulakis KN. Smirnova D, et al. Psychiatr Danub. 2021 Sep;33(Suppl 9):119-129. Psychiatr Danub. 2021. PMID: 34559790
• Psychological and Behavioral Response to the Coronavirus (COVID-19) Pandemic. Balkhi F, Nasir A, Zehra A, Riaz R. Balkhi F, et al. Cureus. 2020 May 2;12(5):e7923. doi: 10.7759/cureus.7923. Cureus. 2020. PMID: 32499970 Free PMC article.
• Changes in Lifestyle, Health Practices, and Perceived Anxiety amidst the COVID-19 Pandemic: A Cross-Sectional Study Conducted on the General Population of Pakistan. Qadri H, Kumar S, Rafique Khan H, Yaqub A, Ullah I, Mukhtar S, Tahir MJ, Munir MU. Qadri H, et al. Med J Islam Repub Iran. 2021 Dec 31;35:195. doi: 10.47176/mjiri.35.195. eCollection 2021. Med J Islam Repub Iran. 2021. PMID: 36060312 Free PMC article.
• Impact of National Lockdown Measures on the Association Between Social Media Use and Sleep Disturbance During COVID-19: A Meta-Analysis of 21 Nations. Cheng C, Chen S, Chen S. Cheng C, et al. Cyberpsychol Behav Soc Netw. 2024 Aug;27(8):527-538. doi: 10.1089/cyber.2023.0571. Epub 2024 Jun 25. Cyberpsychol Behav Soc Netw. 2024. PMID: 38916117 Review.
• Assessment of Mental Health and Various Coping Strategies among general population living Under Imposed COVID-Lockdown Across world: A Cross-Sectional Study. Sameer AS, Khan MA, Nissar S, Banday MZ. Sameer AS, et al. Ethics Med Public Health. 2020 Oct-Dec;15:100571. doi: 10.1016/j.jemep.2020.100571. Epub 2020 Jul 28. Ethics Med Public Health. 2020. PMID: 32838000 Free PMC article. Review.
• Impact of campus closure during COVID-19 on lifestyle, educational performance, and anxiety levels of college students in China. Wang Y, Zhang Y, Wang J, Ge W, Wang L, Jia N, Li S, Li D. Wang Y, et al. BMC Public Health. 2024 Aug 15;24(1):2218. doi: 10.1186/s12889-024-19744-8. BMC Public Health. 2024. PMID: 39148106 Free PMC article.
• Changes in Sleep Duration and Sleep Timing in the General Population from before to during the First COVID-19 Lockdown: A Systematic Review and Meta-Analysis. Ceolin C, Limongi F, Siviero P, Trevisan C, Noale M, Catalani F, Conti S, Di Rosa E, Perdixi E, Remelli F, Prinelli F, Maggi S. Ceolin C, et al. Int J Environ Res Public Health. 2024 May 2;21(5):583. doi: 10.3390/ijerph21050583. Int J Environ Res Public Health. 2024. PMID: 38791798 Free PMC article. Review.
• Bedtime procrastination related to loneliness among Chinese university students during post-pandemic period: a moderated chain mediation model. Xu C, Lin N, Shen Z, Xie Z, Xu D, Fu J, Yan W. Xu C, et al. BMC Public Health. 2024 Feb 16;24(1):491. doi: 10.1186/s12889-024-18019-6. BMC Public Health. 2024. PMID: 38365682 Free PMC article.
• Burnout in early year medical students: experiences, drivers and the perceived value of a reflection-based intervention. Prendergast M, Cardoso Pinto AM, Harvey CJ, Muir E. Prendergast M, et al. BMC Med Educ. 2024 Jan 3;24(1):7. doi: 10.1186/s12909-023-04948-0. BMC Med Educ. 2024. PMID: 38172864 Free PMC article.
• Assessing the health, social, educational and economic impact of the COVID-19 pandemic on adolescents in low- and middle-income countries: a rapid review of the literature. Ramaiya A, Chandra-Mouli V, Both R, Gottert A, Guglielmi S, Beckwith S, Li M, Blum RW. Ramaiya A, et al. Sex Reprod Health Matters. 2023 Dec;31(1):2187170. doi: 10.1080/26410397.2023.2187170. Sex Reprod Health Matters. 2023. PMID: 36987980 Free PMC article. Review.
• Ali M.Y., Gatiti P. The COVID-19 (Coronavirus) pandemic: reflections on the roles of librarians and information professionals. Health Info Libr J. 2020;37:158–162. - PubMed
• Allington D., Duffy B., Wessely S., Dhavan N., Rubin J. Health-protective behaviour, social media usage and conspiracy belief during the COVID-19 public health emergency. Psychol Med. 2020;2020:1–7. [cited 2020 Aug 7; available from: https://pubmed.ncbi.nlm.nih.gov/32513320/ ] - PMC - PubMed
• Anwar K., Adnan M. Online learning amid the COVID-19 pandemic: students perspectives. J Pedagog Res. 2020;1:45–51.
• Bao Y., Sun Y., Meng S., Shi J., Lu L. 2019-nCoV epidemic: address mental health care to empower society. Lancet. 2020;395:e37–e38. [Lancet Publishing Group; cited 2020 Aug 7] - PMC - PubMed
• Bilal, Latif F., Bashir M.F., Komal B., Tan D. Role of electronic media in mitigating the psychological impacts of novel coronavirus (COVID-19) Psychiatry Res. 2020;289:113041. [cited 2020 Aug 7; Available from:/pmc/articles/PMC7194577/?report=Abstract] - PMC - PubMed

Related information

Linkout - more resources, full text sources.

• Elsevier Science
• Europe PubMed Central
• PubMed Central

Other Literature Sources

• scite Smart Citations

Miscellaneous

• NCI CPTAC Assay Portal
• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Sage Choice

Progress of COVID-19 Epidemic in Pakistan

Khadijah abid.

1 College of Physicians and Surgeons, Karachi, Pakistan

Yashfika Abdul Bari

Maryam younas, sehar tahir javaid, abira imran.

2 Liaquat National Hospital, Karachi, Sindh, Pakistan

The outbreak of corona virus initiated as pneumonia of unknown cause in December 2019 in Wuhan, China, which has been now spreading rapidly out of Wuhan to other countries. On January 30, 2020, the World Health Organization (WHO) declared coronavirus outbreak as the sixth public health emergency of international concern (PHEIC), and on March 11, 2020, the WHO announced coronavirus as pandemic . Coronavirus is thought to be increasing in Pakistan. The first case of coronavirus was reported from Karachi on February 26, 2020, with estimated populace of Pakistan as 204.65 million. Successively, the virus spreads into various regions nationwide and has currently become an epidemic. The WHO has warned Pakistan that the country could encounter great challenge against the outbreak of coronavirus in the coming days. This short communication is conducted to shed light on the epidemic of coronavirus in the country. It would aid in emphasizing the up-to-date situation in a nutshell and the measures taken by the health sector of Pakistan to abate the risk of communication.

The outbreak of coronavirus initiated as pneumonia of unknown cause in December 2019 in Wuhan, China, which has been now spreading rapidly out of Wuhan to other countries. 1 On January 30, 2020, the World Health Organization (WHO) declared COVID-19 outbreak as the sixth public health emergency of international concern (PHEIC), and on March 11, 2020, the WHO announced COVID-19 as pandemic . 2 On April 9, 2020, nearly 1 436 198 cases of 2019-novel coronavirus recorded out of which 85 522 died with a case fatality rate (CFR) of 5.95%. The WHO evaluated the global risk of COVID-19 as very high. In the coming days and weeks, the amount of events, fatalities, and affected countries is projected to increase sharply. 1

COVID-19 is thought to be expanding in Pakistan. The first case of COVID-19 was reported from Karachi on February 26, 2020, with estimated populace of Pakistan as 204.65 million. 3 , 4 Successively, the virus spreads into various regions nationwide and has currently become epidemic. Within 45 days, on April 10, 2020, the Pakistan’s tally has reached 4601 confirmed cases of COVID-19, 727 patients have recovered, and 66 have died. 4

This short communication is conducted to shed light on the epidemic of coronavirus in the country. It would aid in emphasizing the up-to-date situation in a nutshell and the measures taken by the health sector of Pakistan to abate the risk of communication.

Situational and Epidemiological Analysis

According to Pakistan’s last update 4 at 9:17 am on April 10, 2020, 54 706 suspected coronavirus cases were reported in Pakistan, 4695 of which tested positive for COVID-19 (8.6%). Of the 4695 cases, 727 patients recovered (15.5%), 45 remain critical (1%), and 66 died (CFR: 1.4%). Coronavirus attack rate is estimated to be 2.3 per 100 000 Pakistani population. Nearly 49% of cases are registered from Punjab. The cumulative reported cases of COVID in Punjab increased by 53.2% (1493 cases to 2287 cases) from April 5 to April 10, 2020. Sindh recorded the second highest number of incidences (26%) followed by Khyber Pakhtunkhwa (KPK; 13.2%). From April 5 to April 10, 2020, the cumulative reported cases of COVID increased by 28% (881 cases to 1128 cases) in Sindh and in KPK from 205 cases to 620 cases. Azad Jammu Kashmir (AJK) recorded the lowest number of incidences (0.7%) followed by Islamabad (2.3%). District wise, 880 cases have been confirmed from Lahore (19%) and 871 cases from Karachi (18.9%). Gilgit Baltistan (GB) has the highest rate of recovery (52%), while KPK has the lowest rate of mortality (3.5%) compared with other regions of Pakistan ( Figure 1 ).

Pakistan situation report (April 10, 2020—7:20 pm ).

About 28.2% of the 4695 cases are female, and 71.8% are male. Overall, the 20 to 39 age group is most affected by COVID-19, in which 21.8% being females and 78.2% being males. In Baluchistan, most cases belonged from age group 22 to 48 years, in Sindh from age group 22 to 52 years, and in Punjab from age group 22 to 44 years. Whereas in AJK and GB age varies from 31 to 60 years. When planning initiatives, attention must be given to the age groups mentioned above 4 ( Figure 2 ).

Age and gender-wise distribution of COVID-19.

About 138 health care professionals have contracted coronavirus. Major chunk of infected health care professionals were from Sindh (61.5%), 18.1% were from Baluchistan, 8.7% were from Punjab, and 1% to 5% were from KPK, Islamabad, AJK, and GB. Out of 138 health care professionals, 48% were from age group 21 to 40 years, followed by 40% from age group 41 and older. Majority of the infected health care professionals are male. 5

Recently, the incidence of COVID-19 has increased due to travel to other parts of the world. Pakistan has trade and travel with Iran and China. The increased influx of travelers through land, air, and sea put Pakistan at higher odds of further spread of coronavirus from neighboring countries. The possibility of further importation of the virus into Pakistan is very high, and because Pakistan has already imported the virus, the country needs to take stringent measures to detect potential cases early in order to curb existing epidemic and tracking steps to prevent further spread. After the unexpected rise in coronavirus cases in Pakistan, the Government of Pakistan has halted trade and transport operations with Iran. Now owing to severe snowfall the land connection with China is blocked. Whereas mobilization is tightly controlled at the boundaries of Chaman and Taftan. Additionally, it monitors external travel to Iraq, the Kingdom of Saudi Arabia, and Iran. Weekly, 41 flights operate in Pakistan from three cities (Karachi, Islamabad, and Lahore) and to two destinations in China (Urumqi and Beijing). The danger of virus importation into Pakistan is very high and needs good precautions and strict steps to identify possible cases early and surveillance steps to deter further virus transmission. Pakistan is still in the containment process. The step to shutdown point of entry and borders has been taken. All international flights have been cancelled. In this way, the number of cases might not increase as most of the spread was through worldwide migrants and yet it is impossible to find the point of origin.

With increasing cases of immensely contagious COVID-19, Pakistan’s economy is under great deterioration. The terror of fatal disease and economic distress have come up together. The country cannot bear extended lockdown and should the lockdown extend, Pakistan will suffer unmanageable economic loss. Pakistan does not have any sufficient resources to provide for the patients at the moment. Most of the populace is working on daily wages. The shutdown of the whole country would cause death either due to hunger or from COVID-19. The current statement of Pakistan’s prime minister calls for a community meeting among susceptible countries that are dealing with the pandemic. It has been decided that rather than complete shutdown, people should avoid mass gatherings, and partial shutting down of the country will take place in order for the economy to provide for basic necessities. 4

Conclusion and Recommendations

COVID-19 is swiftly spreading worldwide. Within a few months, the mortality rate and morbidity rate has reached unexpected levels. The clinicians are working to invent treatments and vaccine to prevent this infection. The extreme situation is yet to occur. However, if we take one step toward self-isolation, it could save the entire community and the risk will decline immediately. This is a situation where each individual has to take steps toward minimizing the risk by staying in the house and immobilizing themselves. The airborne, contact transmission can only be disinfected if proper handwashing protocols are followed and each individual carry out precautionary measures to safe other individuals from this debilitating virus. Pakistan has a tremendous potential in public health, and different sectors can work together to address the challenges by the engagement of society and community along with policy initiatives.

Authors’ Note: The datasets used during the current review are available on online at http://www.covid.gov.pk/ and https://www.nih.org.pk/ .

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

• Get Involved

COVID-19 pandemic

Covid-19 pandemic response.

Humanity needs leadership and solidarity to defeat the coronavirus

The coronavirus COVID-19 pandemic is the defining global health crisis of our time and the greatest challenge we have faced since World War Two. Since its emergence in Asia late last year, the virus has spread to  every continent  except Antarctica. Cases are rising daily in Africa the Americas, and Europe.

Countries are racing to slow the spread of the disease by testing and treating patients, carrying out contact tracing, limiting travel, quarantining citizens, and cancelling large gatherings such as sporting events, concerts, and schools.

The pandemic is moving like a wave—one that may yet crash on those least able to cope.

But COVID-19 is much more than a health crisis. By stressing every one of the countries it touches, it has the potential to create devastating social, economic and political crises that will leave deep scars.

We are in uncharted territory. Many of our communities are unrecognizable from even a week ago. Dozens of the world’s greatest cities are deserted as people stay indoors, either by choice or by government order. Across the world, shops, theatres, restaurants and bars are closing.

Every day, people are losing jobs and income, with no way of knowing when normality will return. Small island nations, heavily dependent on tourism, have empty hotels and deserted beaches. The International Labour Organization estimates that 25 million jobs could be lost.

UNDP response

Every country needs to act immediately to prepare, respond, and recover. The UN system will support countries through each stage, with a focus on the most vulnerable.

Drawing on our experience with other outbreaks such as Ebola, HIV, SARS, TB and malaria, as well as our long history of working with the private and public sector , UNDP will help countries to urgently and effectively respond to COVID-19 as part of its mission to eradicate poverty, reduce inequalities and build resilience to crises and shocks.

“We are already hard at work, together with our UN family and other partners, on three immediate priorities : supporting the health response including the procurement and supply of essential health products, under WHO’s leadership, strengthening crisis management and response, and addressing critical social and economic impacts.” UNDP Administrator, Achim Steiner

Responding with people at the centre

Pakistan has witnessed a massive increase in its confirmed cases from the initial two confirmed on 26th February 2020. As a country whose economy is highly reliant on manufacturing and service industries, shutdown measures and disruptions in supply chains will negatively impact on the economy and society, particularly the poor. 

As in other countries, the pandemic is likely to stress the capacity of the public health system and result in loss of human lives.  Severe repercussions on livelihoods, especially of the most vulnerable, dependent on government support, are expected.  The shutdown measures have already impacted small businesses, small and medium enterprises and daily wagers associated with various sectors of the economy. Considering that the informal sector in the country accounts for a major share of the national economy[1] and employs 27.3 million individuals, an increase in un(der)employment and poverty coupled with implications on food production and overall food security are anticipated.

The Government of Pakistan is concerned with the social and economic implications of COVID-19 and has established, with the help of UNDP, a COVID-19 Secretariat in the Planning Commission to prepare a coordinated economic and social response and design evidence-informed interventions. The Secretariat is required to ensure adequate coordination between Federal and Provincial Governments, with UN and Development Partners.  

In this regard, the federal government as well as provincial government of Khyber Pakhtunkhwa have requested UNDP’s support on a range of areas including coordination, strategic communications, crisis management, business continuity and digital solutions to manage government response to the pandemic. Assistance with procurement of medical supplies and equipment is also being discussed.

Against this background, UNDP is currently in the following activities in response to COVID-19 in Pakistan.  (This page will be updated regularly.)

Supporting the Federal Government in coordination and strategic communications:

• Supporting the Planning Commission in establishing a Secretariat for coordinating socio-economic impact of COVID-19;
• Supporting the Federal Government and Khyber Pakhtunkhwa Government with Strategic Communications and Awareness;
• Supporting Economic Affairs Division to design ODA coordination system (aid effectiveness).

Supporting Ministry of Health and Khyber Pakhtunkhwa Government in health system response:

• Capacity support in crisis management and provision of digital solutions to enable business continuity;
• Supporting Khyber Pakhtunkhwa Government to enhance supply chain management (including procurement of health supplies and equipment).

Coordination of UN socio-economic impact needs assessment to identify mitigation responses:

• Impact assessment on the most vulnerable, policy recommendations & proposed programme interventions, to feed into the national action plan for COVID-19.

[1] The figure ranges from 18.2% to 71% based on different analysis 

While we do this, we must also consider ways to prevent a similar pandemic recurring. In the longer term, UNDP will look at ways to help countries to better prevent and manage such crises and ensure that the world makes full use of what we will learn from this one.

A global response now is an investment in our future.