Crisis, resilience, and innovation interwove intricately in the response to SARS-CoV-2 epidemic by Pakistan (1, 2). Pakistan has a wide health infrastructure with many public sector resources that are not always coordinated (1, 3, 4). The coordination is further challenged under the 18th amendment to the constitution which devolved the responsibility for health management to provinces independently. Thus, although many necessary pieces to fight the epidemic were present, they were not necessarily best placed to do so, and many others had to be developed. Foremost a coordination mechanism was needed to synchronize a massive multisectoral response comprising all aspects of the society. The effectiveness of this response is evident from the fewer case transmission and deaths due to COVID-19 in Pakistan, compared to its regional neighbors (2, 5). We explore how this response unfolded and what lessons may be learnt from it.

The initial lack of knowledge of the novel biology and transmission potential of COVID-19 caught governments all over the world by surprise and led to widely varying health system responses in different countries. For instance, the Chinese government responded with centralized control, devoted considerable resources to medical facilities and initiated sweeping lockdowns (6, 7). Other Asian economies like Singapore, Hong Kong, and South Korea also relied on COVID-19 testing, isolation and quarantine. Some European countries such as Italy and Spain, at least initially, hesitated to lockdown and delayed containment measures. The United States with its federal structure of governance, saw diverse responses that ranged from very strict lockdowns, school and business closures and stringent masking to very open or even laissez-faire approaches. While some of this variation was in response to different types of the epidemic between US states, at least some of it was driven politically (8). These myriad variations in response served as natural experiments that over time provided information about alternate scenarios, responses and improvisations.

Countries applied lessons from previous experiences with outbreaks to their COVID-19 management (9). Many mounted centralized responses (9, 10), acted quickly (11, 12), and devoted substantial public funds up front. Pakistan spends relatively little in health, has a high burden of communicable diseases (2), and few systems to combat them, save perhaps an elaborate system to identify polio cases. In managing the epidemic, Pakistan had to manage the surging cases, and deaths while counterbalancing extensive economic and social disruption from lockdowns (13).

This paper attempts to document the national COVID-19 response of the Government of Pakistan. It describes central coordination by the federal government, its political cooperation with the legally devolved provinces to coopt and build upon existing structures, while creating new ones that were needed. Our goal is to look at Pakistan as a case study of managing pandemics in developing countries.

This descriptive paper outlines how Pakistan’s COVID-19 response evolved, by describing what systems existed, what additions were made, and the processes of the response. The information about administrative structures of the relevant institutions and stakeholders, as well as about the policy response to disease containment, comes from attending the daily official meetings of the National Command and Operation Center (NCOC), regular meetings of the National Coordination Committee (NCC), which was formed to respond to the pandemic, and personal meetings with officials of Ministry of National Health Services, Regulations and Coordination (MoNHSRC), National Institute of Health (NIH), National Emergency Operation Centre (14), and the National Database and Registration Authority (NADRA) who participated in aspects of the national COVID-19 response. We also used government and other reports, journal articles, newspapers and media sources where needed.

The initial response to the pandemic included a review of existing processes and institutions to seek what could be coopted in the response.

The Government of Pakistan implemented a range of non-pharmaceutical interventions to control the spread of COVID-19, that included mask-wearing in public, social distancing, lockdowns that ranged from nation or citywide to targeted smart and micro localized in individual localities, travel restrictions (both inbound international flights and inter-country travel), limitations on tourism, school closures, and restrictions on public gatherings and weddings (15, 26, 27, 33, 34). These measures, announced as Standard Operating Procedures (SOP), were implemented dynamically, with restrictions being eased and tightened based on real time information from individual localities.

By late 2020, Pakistan’s containment measures had become well-established and effective (26), and were able to address subsequent waves of COVID-19 (Figure 4). As a result, government policy focus shifted from crisis management to enabling a return to normalcy with consequent changes in the national response. The first step toward this change was an overall easing of restrictions, particularly blanket lockdowns that had large economic and political costs. Based on analysis from analysis teams, a targeted approach was applied to monitoring and containing COVID-19 through smart lockdowns (SLDs) and mini-Smart lockdowns (mini-SLDs) at the street, neighborhood, or citywide levels. Predictions were made based on population density and local positivity. These locales were “sealed” by the local administration, restricting movement in and out of these areas. COVID-19 positivity rate was used as an indicator to monitor the spread of COVID-19 in these areas.

Throughout the latter months of 2020 and well into 2021, the targeted approach was applied whenever case positivity rose (on tests from hospitals, laboratories and TTQ), institutionalization of SLDs or mini-SLDs, periodic school closures, lowered attendance at wedding or other public functions, reducing market hours, and limiting public gatherings. This approach continued irrespective of the COVID-19 variant that was driving that wave.

The quality of implementation was monitored daily by TTQ and special NEOC/PEOC teams that reported with pictures, and rapid surveys to assess mask wearing, number of people in marketplaces, and attendances at public events such as wedding or religious ceremonies. Occasionally, artificial intelligence-based algorithms were applied to quantify this effectiveness of implementation, for example by estimating the percentage of masking in public places. However, this was sporadic given its high costs. Initially many SOP were followed voluntarily. However, as vaccination rates grew and people felt more comfortable, adherence fell. Since ensuring compliance with such SOP were resource intensive, by 2022, as a significant proportion of the population had been vaccinated, most restrictions started being lifted.

A core feature of NCOC was its intersectoral and inter-ministerial approach to formulate a unified COVID-19 pandemic response. The NCOC collaborated with various government ministries, civil administration, private sector organizations, and civil society organizations to develop and implement strategies to contain the spread of the virus. Daily meetings at the NCOC helped with the coordination. Various ministries played crucial roles. For example, the Ministry of Interior was crucial in enforcing lockdowns and implementing SOP across the country (28, 29). The Ministry of Industries and the National Disaster Management Authority (NDMA) led the ramp up in the capacity to meet oxygen needs in hospitals (35).

As hospitalizations rose, there was a critical shortage of medical oxygen. The national supply at the time was around 350 metric tons a day of which two thirds was for commercial or industrial use. At the peak of hospitalizations, particularly during the third wave (Table 1), medical oxygen requirements exceeded 400 MT/D. As a result, the bulk of the oxygen produced in the country was diverted toward the treatment of COVID-19 patients, exacerbating the scarcity of medical oxygen for other medical conditions (34). In the short-term oxygen was diverted from industry to medical use. In the longer time, local oxygen generation capacity was increased. For example, the Chinese government donated 200 oxygen generators (concentrators) worth 3 million yuan ($463,943) (36), and the United Nations Children’s Fund (UNICEF) contributed 1,000 oxygen concentrators and related accessories valued at USD 1.4 million (37). Other friendly countries such as Saudi Arabia also funded to build further capacity, to the point that the national capacity had increased to over 800 MT/D toward the end of the fifth wave. A new critical care hospital was established at NIH, Islamabad co-funded by Government of Pakistan and China. The prefabricated building was completed by NDMA in less than 2 months and its personnel were hired by the health ministry through walk-in interviews in days through a unique arrangement of service agreements with the approval from the federal cabinet.

Other collaborations included the Federal Ministry of Education, provincial education, and private schools’ organizations for policy decisions regarding closing or reopening educational institutions to control disease spread. The Ministry of Religious Affairs, the Pakistan Ulema Council (PUC), a nongovernment organization comprising of Islamic scholars from different school of thought and the Council of Islamic Ideology (CII), a federal constitutional body that provides advice on Islamic law, also issued guidelines and decrees to promote the postponement of religious gatherings and adherence to government SOP.

Charitable organizations such as the Chhipa Welfare Association and the Edhi Foundation provided relief packages and essential goods to thousands of poor households affected by the pandemic, along with ambulance services for COVID-19 patients (38). A number of philanthropies supported individuals that faced economic hardship due to limitations in employment during lockdowns. A large rural focused consortium of NGOs, the Rural Support Programs (RSPs), were engaged repeatedly to implement SOP to support vaccination and to identify poor households for distribution of food and other necessities (39).

Effective communication was a cornerstone of Pakistan’s COVID-19 response. A Communication Cell was created at the Ministry of Health with the assistance of Bill and Melinda Gate Foundation and UNICEF, where a team of communication experts guided messaging, and gaged, monitored and responded to any misinformation or disinformation on all aspects of COVID spread and evolution of the disease, and about vaccine or epidemic countermeasures on social media, print media and electronic media. It also helped coordinate among government departments, disseminating COVID-19 guidelines to a diverse set of public and private stakeholders, and keeping the public up to date on cases, preventive measures, and vaccination. Under guidance of the health ministry, the cell gave daily or weekly briefings to the NCOC and monthly reports to the ministry on all issues and steps taken to counter false or incorrect information.

The NCOC convened various private stakeholders and government departments at federal or provincial levels to build consensus and chalk out strategies. Communication at the NCOC was guided by the MoNHSRC and operationalized by the Ministry of Information and Broadcasting and the military’s Inter Services Public Relations (ISPR) wing. Relevant content was produced regularly, sometimes daily and communicated through various channels, including conventional mail, telephone, print media, press releases, official notifications, infographics, SMS, public service message videos, TV and radio shows, digital and social media, caller ring tones, and a dedicated website ⁵ that depicted daily changes in the epidemic situation and vaccination status. Explanations were provided to help the public understand the situation, so that terms such COVID-19, virus, positivity, etc. became part of daily vernacular. Important events and news were conveyed directly from NCOC through press conferences held by the ministers of health and planning and the DG NCOC.

Technology guided the vaccination rollout. People were reached and could check their eligibility status, find vaccination centers, and book vaccination appointments through mobile phones. A dedicated portal was created by the NADRA for the public to retrieve vaccination records and certificates. The front-end access was available through website ⁶ and the PAK COVID-19 Vaccination Pass application was deployed on Android and Apple platforms.

Pakistan funded the response to the COVID-19 pandemic from multiple sources. Initial allocation was for PKR 1.240 trillion through the Economics Stimulus Package (ESP) (43). By June 30, 2020, PKR 354.23 billion (USD 2.25 billion), had already been released to address aspects of the response. An Emergency Response Package was established within the ESP for PKR 190 billion, to support the NDMA, provide medical equipment and incentives for healthcare workers, offer emergency relief funds (including cash relief through the Benazir Income Support Program), and grant tax relief on essential food and health items. Furthermore, an Emergency Relief Fund was established by the Finance Division, with an additional grant of PKR 417.28 billion. The fund included PKR 380 billion from a supplementary grant and PKR 100 billion from the Residual/Emergency Relief Fund of the ESP to eventually total PKR 480 billion for emergency relief efforts.

In addition to the government funding initiatives, Pakistan received substantial grants and loans from international donors to support its response to the COVID-19 pandemic. Multilateral grants totaling USD 28.45 million were committed by the Asian Development Bank (ADB), European Union (EU), Islamic Development Bank, and the United Nations (UN). Bilateral grants amounting to USD 70.626 million were also pledged by countries including Canada, China, Japan, South Korea, the United Kingdom, and the United States. In addition, ADB, Islamic Development Bank, and the World Bank committed loans worth USD 721.17 million (43).

In Pakistan, the National Institute of Health (NIH) is responsible for managing epidemics and infectious diseases as it serves as the surveillance and implementation arm of the MoNHSRC. However, when COVID-19 pandemic started, limited capacity at the NIH necessitated the formation of the NCOC to control the pandemic. After successfully managing the national response, the NCOC was dissolved in March 2022. The administration of vaccines and monitoring of pandemics were then officially transferred to the NIH, which took over surveillance responsibilities at the end of the fifth wave of the pandemic, albeit at the pre-epidemic levels (44).

Pakistan had many of the elements needed to mount an effective response to the COVID-19 pandemic in 2020. However, several of these existed in silos, with little mutual coordination and performed inconsistently. The crucial driver of Pakistan’s very effective response was the establishment of a coordination system that was led by the top leadership in Pakistan, and included various political, military, and civil society actors in a common decision making and implementation mechanism. This coordination was top down, yet inclusive of disparate views, respectful of provincial and private sector autonomies, yet decisive and single minded when difficult decisions were needed. It built or repurposed the data and implementation systems that were needed and relied heavily and routinely on data to hold implementers accountable.

Pakistan has a very large healthcare infrastructure that includes more than 18,000 public sector and likely over 75,000 private health facilities, and disease specific surveillance for polio and measles. Data systems in the private sector seldom feed into any national repository. Most importantly, the NIH where the COVID-19 response could have been housed was insufficiently staffed or motivated to participate, leaving a vacuum that had to be filled. Finally, since the 18th Amendment to the Constitution in 2010, provinces have felt strongly about their autonomy and seldom communicate or collaborate with each other. The NCOC was able to provide that coordination platform. This support was widely accepted by provincial governments, civic organizations, and the society at large partly due to the unprecedented situation unfolding globally and a broad-based national consensus on the necessity for an effective response to the pandemic. Provinces discussed and addressed differences. Decisions followed data, to ensure ideas were translated into practice and identify lags in implementation and fixed it through troubleshooting (7, 9, 10). Overall, at least part of the consensus came from the sense that the NCOC was making data-based decisions, that were fair and that the quality and scope of data brought into use was superior to anything provincial officials had access to on their own.

The political arrangement of the COVID response was crucial. All federal minsters participated at the NCC where provincial chief ministers were also invited regularly. The NCOC leadership included the planning minister to facilitate financial allocations, the health minister provided technical expertise and the military team ensured implementation in two ways. Firstly, it provided personnel to carry out tasks. At its peak, NCOC had nearly 300 personnel assigned to it, including two one- or two-star generals and over 10 brigadiers. By contrast, most ministries do not have nearly that many personnel. For example, the MoNHSRC has 31 sanctioned officer positions at its head office, and fewer than 5 of these are grades 20 or above, and only around a third are filled at any point. Having sufficient personnel and of appropriate seniority and experience was crucial, as those assigned to the NCOC could dedicate all their time to NCOC work, whereas most MoNHSRC and NIH personnel would have split their time between COVID-19 work and their routine assignments simultaneously. Having additional personnel meant that military staff could be assigned as additional personnel when needed in districts. Finally, having uniformed staff provided necessary impetus as teams could induce work from district or even provincial administrations.

One of the most important lessons learnt was that the senior leadership in Pakistan saw COVID-19 as an existential and political threat and responded accordingly. All actors came aboard, although there were differences, that were aired and addressed, and definitive actions were taken. Even while the response was ongoing, the level of implementation, cooperation between actors, and compliance by the population waxed and waned, in time with the ebb and flow of the epidemic. However, once survival pressure abated, the situation reverted to the usual patterns with lowered focus on results or coordination (45).

Success of compliance of the public with the restrictions placed during the response partly reflects the authoritarian nature of the implementation process. COVID-19 SOP were communicated to the public as directives, and violations by businesses or individuals were penalized (1, 46, 47). This likely contributed to the overall effectiveness of the SOP enforcement in Pakistan. Globally, such authoritarian approaches were part of many successful responses (10, 48), and reflect the Ding and Li framework of “rough rationality with limited resources” (49). In essence there is a tradeoff between using limited resources to find and heavily penalizing a few offenders publicly vs. universal enforcement, testing and contact tracing (50). Pakistan opted for the former given its resource constraints (11, 51).

The experience of managing the COVID-19 response successfully created many lessons that can inform a more proactive approach to emerging health and other threats, particularly in resource constrained countries (9). These lessons inform about diverse aspects of resource allocations, institutional arrangements, galvanizing the civil society and general public, and generating political consensus. These unique lessons allow insights into how a socio-economically challenged country with a wide array of constitutional and political actors with diverse ethnicities worked toward reducing the impact of COVID-19 despite their often-diverging priorities. Of importance is how although there were several government entities that are tasked with aspects of such responses, seldom talked with each other, or used data to guide or coordinate actions (52). This status quo reflected, and still does in the post COVID-19 times, of political economy of government functions that are conducted as “activities” rather than to achieve policy objectives such as managing current or mitigating future emergencies. They were brought together on an effective platform that measured and delivered results when an imminent and existential threat was perceived. However, there is a danger that the many lessons learned from responding to COVID-19 may be lost now that the existential threat has receded (45).

The data analyzed in this study is subject to the following licenses/restrictions: the data was provided to the Akhter Hameed Khan Foundation team for this study as part of its work with Pakistan’s Federal Ministry of National Health Services, Regulations & Coordination (MoNHSRC) and the National Command & Operation Centre (NCOC) in Islamabad, which lead Pakistan’s response to the COVID-19 pandemic. The AHKF 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). The parentage of this data is with the NCOC and the MoNHSR&C. The AHKF 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 MoNHSRC. Requests to access these datasets should be directed to Dr. Shahzad Baig, Email: eocpakistan@gmail.com.

AdK: Writing – review & editing, Validation, Supervision, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. MA: Writing – review & editing, Writing – original draft, Resources, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. RK: Writing – review & editing, Writing – original draft, Resources, Methodology, Formal analysis, Data curation. TK: Writing – review & editing, Writing – original draft, Resources, Investigation. FS: Writing – review & editing, Validation, Supervision, Resources, Project administration. SA: Writing – review & editing, Resources. AaK: Writing – review & editing, Validation, Supervision, Resources, Project administration. AyK: Writing – review & editing, Validation, Supervision, Project administration, Methodology, Funding acquisition.