Pakistan’s Humanitarian Response Plan for COVID-19
By Shafqat Munir
Introduction
With 220 million population, Pakistan stands as the 5th most populous country in the world and the 17th among the most COVID-19 affected countries. The ecnoteonomic situation which was already seeing a low is now assailed by miseries of the pandemic and the poor and vulnerable populations – daily wage workers, small shopkeepers, self-employed persons and families, home-based workers and vendors – have been impacted to a larger extent. An estimated 6.65 million people, including Afghan refugees, internally displaced persons (IDPs), undocumented Afghans and the people affected as a result of recent natural disasters have been suffering from health and non-health impacts of COVID-19.1 The already existing vulnerabilities of such groups have further been aggravated in terms of growing stresses among family members, loss of jobs and reduced or no income/livelihood options amid social distancing and lockdown of various sectors connected to the job market. Millions of children are out of schools and most of them have no facility to get classes on digital platforms as their parents cannot afford to buy digital devices and Internet connections.
Following the footsteps of other countries – developed and developing – Pakistan is entering into a COVID-19 new normal with opening up of various sectors of the economy with certain Standard Operating Procedures (SoPs); and calling upon the people to be careful and protect themselves from contracting the virus. Opening up of the economy and urging people to be extra careful amid relaxed lockdown is a bid to create a balance between the deaths due to the corona virus and the destruction due to a jammed economy. The lockdowns have their consequences over the economy and mental health of the people. The lockdowns can provide new opportunities if utilized in positive activities at home; and in times of lockdown-relaxation, one needs to exhibit extra care while moving out of home as responsible citizens. This is the crux of the new normal response plan to COVID-19 in Pakistan.
Situation analysis of COVID-19
The number of infected cases has risen from 57192 on April 14, 2020, to 1011733 as of June 7, 2020 – over 17 times more. The number of reported deaths as on April 14, was 96 and now the number reached 2032 with 65,073 active cases as of June 7, 2020, an alarming ratio. As of June 7, 2020, a total of 34068 patients have recovered. The authorities and expert estimate that after the incubation period of relaxation in the lockdown during the last week of Ramzan and Eid holidays (last week of May 2020), the number of cases may rise further – from June 12, 2020, and until mid-July. This will also depend upon how many are tested. The situation for July 2020, seems to be tougher as per the estimates amid the opening of a large number of sectors of economy and reports that the people are not observing the SoPs at crowded places, markets, etc.
In an alarming situation, it has been disclosed on June 1, 2020, that a summary sent to the Punjab Chief Minister Usman Buzdar on May 15, 2020, estimated that 670,000 people in Lahore alone may be affected by the corona virus. Quoting the Secretary, Primary & Secondary Healthcare Department, Pakistan’s GEO TV reported that this figure has been drawn from the results of samples collected from hotspots, residences and offices in Lahore. The summary says that 6% of the total samples collected tested positive for COVID-19 whereas they were up to 14.7% in some localities.
Humanitarian Response Plan /National Plan of Action
The Global Humanitarian Response Plan sets funding target for Pakistan’s COVID-19 Response Plan as US$ 126.8 million, out of which only US$ 25.9 million have been committed by the global community which is just 20.4% of the actual estimates. The funding appeal remains largely unmet.4 This is, however, somewhat better than the global average which stands at 17.4% met with so far by US$ 1.18 billion (contributed) against the target of US$ 6.82 billion.
According to the ‘Pakistan Humanitarian Response Plan for COVID-19 Pandemic 2020 updated on May 22, 2020, the coronavirus cases have been reported in 115 out of 158 districts. The country’s prime health testing facility, the National Institute of Health, reports that people from 20 to 49 years of age comprise 53% of the total cases. The Response Plan, prepared by experts from UN agencies, government and others, based on the predictive analysis looking at the growing number of cases, projects that the number of COVID-19 cases may reach 196,000 in the forthcoming month with 15% rendered as moderate to severely ill while 5% may get critical needing ventilators.5 This number has already reached 101173 as of June 7, 2020.
Since over a hundred laboratories in Pakistan with a testing capacity of over 20,000 people per day are performing tests of a limited number of at-risk populations, it is feared the bulk of untested population may upset indicative analyses (regarding the number of actual cases and deaths) during the forthcoming months. When compared with other sectors that have been hit by the COVID-19 pandemic, the health sector is the biggest one that needs humanitarian assistance in terms of protection of frontline health workers, including doctors, nurses and other paramedical staff as thousands of them are reportedly infected by the corona virus and hundreds of them have lost their lives. Moreover, all health facilities, clinics and hospitals have stopped their other operations, except for emergency services which have impeded immunization, preventive health care, pre and post-natal care and other critical diseases. Most of the planned surgeries have been postponed. Similarly, health-related nutrition programs in drought-hit areas have also been suspended affecting some 200,000 women and 400,000 children from poorest of the poor.6
The estimates quoted in Pakistan Humanitarian Response Plan for COVID19 Pandemic 2020 (updated May 22) hints at an increase in the number of people living below poverty from the exiting 50-60 million to 125 million as an impact of COVID-19. A quarter of the population, some 53 million people, live below the national poverty line and 84 million people fall under the category of the multi-dimensionally poor. An estimated 40-62 million people are persistently and chronically vulnerable to food insecurity while they are also exposed to natural hazards. These populations are at risk of falling into the increased food insecurity requiring a scaled-up response by humanitarian partners through both in-kind and cash modalities.
Response strategy under the Response Plan
There have been five top priorities to handle during the pandemic: to make people aware of observing relaxed lockdown; to develop awareness of washing hands, maintaining social distance, wearing face masks and avoiding touching face, nose and mouth after contacting any surface or amid crowds; to ensure cash transfers and emergency food supplies to the needy and the poor so that they do not die of hunger and remain without humanitarian aid; to increase COVID-19 testing facilities at the centre and provincial headquarters levels; and, to handle education sector where millions of students were either waiting for their examinations to be conducted or results declared and kickstart online education.
Pakistan has responded to the pandemic by imposing a lockdown and providing cash grants to millions of the poor and daily-wage workers. The government has announced relief packages for small and medium enterprises and businesses and some other sectors. Pakistan has been able to quickly move to cash grant disbursements because a cash grant social protection network under Benazir Income Support Programme (BISP) and its expanded scope to ‘Ehsass’ social protection programme of the Imran Khan-led Pakistan Tehrik e Insaaf (PTI) government, was already in place. A lump sum amount of Rs 12,000 has been provided to some 12 million families through these programmes. Pakistan provided cash grant from its own resources under the country-wide social protection programme which was designed for women but was later expanded to the men too in dire need of cash to meet COVID-19 impacts.
COVID-19 is not just a health hazard, it is a grave emergency for health and livelihood. Since this pandemic requires social distancing which has badly impacted the livelihood of people. The State Bank of Pakistan has predicted that if the situation continues like this, then a large number of companies may go bankrupt and millions more rendered unemployed. A large chunk of the economy depends on small to medium level manufacturing, agricultural produce and service industries. Pakistan stands at 152 out of 189 countries on the Human Development Index (HDI) 2019 with a high level of health inequality in South Asian countries (ranked 105 out of 195 countries on the Global Health Security Index 2019). Amid this state of affairs and rising number of the COVID-19 cases, public health experts are worried about Pakistan’s ability to deal with the virus.7
Pakistan is prone to all sorts of health pandemics, epidemics such as hepatitis, measles, polio, HIV/AIDS, dengue, Crimean Congo flu and other diseases; and disasters and hazards including flash floods, droughts, cloudburst, earthquakes and fires and conflicts/incidents of terrorism and violent extremism. Pakistan has been able to cope with these emergencies as its humanitarian and response mechanism are in place from the centre to the local levels, with the support it gets from donors and the international community in addition to the country’s own resources to handle such emergencies.
Above all, strengthening of the resilience of communities at local levels under an inbuilt social protection system boosts the resilience of the communities in coping with all sorts of shocks, be they from a pandemic, disaster or economic slowdown. The existing community resilience is largely helping to reduce and address the impacts of the spread of COVID-19. The federal and respective provincial governments immediately mobilized the available social protection mechanisms- Benazir Income Support Programme (BISP) and ‘Ehsaas’ programme- humanitarian infrastructure under National Disaster Management Authority (NDMA), Provincial Disaster Management Authorities (PDMAs) and District Disaster Management Authorities (DDMAs) and urgently disbursed money available at the National Disaster Management Fund (NDMF) to give cash to the needy and the poor so that they can fight back the pandemic; and to buy medical equipment, such as ventilators, isolation beds, testing kits, surgical face masks, N-95 masks and Personal Protection Equipment (PPE) for the frontline workers including doctors and paramedical staff.
Pakistan also put in place its existing public sector health infrastructure that includes 1201 hospitals, 5518 Basic Health Units, 683 Rural Health Centres, 5802 Dispensaries, 731 Maternity and Child Health Centres, 347 TB communities and 123,394 hospital beds. Furthermore, the human resource includes around 200,000 doctors, 100,000 nurses and over 95,000 Lady Health Workers. In addition to the existing health facilities, the authorities also made available make-shift hospitals and isolation wards with thousands of beds in case the COVID-19 caseloads exceed. There is a network of private health institutions in all major cities and these also have facilities to handle COVID-19 patients. Though there have been some complaints regarding the non-professional attitude of some of the private and public sector healthcare staff and management of the hospitals.
In Pakistan’s COVID-19 response, an interesting dimension is the local and individual charity which played a great role in feeding people and providing them with cash for their day to day needs. Due to religious obligation, Muslims, who form a predominant majority of the country, pay their zakat (2.5% of the value of their fixed assets and deposited cash, jewellery, etc., during an Islamic calendar year). When the COVID-19 pandemic hit, it was the time of peak charity amid the holy month of fasting (Ramzan) and people paid in advance from their zakat to the needy and the poor and continued paying it during and after Ramzan too. This charity annually amounts to billions of Pakistani rupees. This money provided relief to the needy. Almost all households paid to their domestic workers their salaries even if they did not come to work; the small businesses and industry diverted their CSR funding or other resources to retain their daily wage or salaried workers. Civil society organizations, local charities and humanitarian agencies also played their expected roles in responding to the pandemic across Pakistan.
In addition to other donors, the World Bank in April 2020, approved a $200 million package for Pakistan to respond to the COVID-19 pandemic. This money was aimed at strengthening national healthcare systems and mitigating socioeconomic disruptions. The Bank also allocated $38 million from its eight ongoing projects by re-purposing the objective to cater to the medical equipment and supplies.8 The Pandemic Response Effectiveness Project (PREP) of the Bank focused on helping the poor and vulnerable fight the pandemic by benefitting from social protection measures, emergency food supplies, and distance education using digital platforms. The Bank funding under Fact Track Facility is being spent on establishing isolation wards and quarantine places in private and public sector hospitals including the supply of ventilators and Personal Protection Equipment (PPE) for doctors and paramedical staff. The Bank’s funding is equally benefitting volunteers and staff providing front-level service to the COVID19 patients. The beneficiaries of the funding include corona infected people, at-risk populations, medical and emergency personnel, service providers in medical and testing facilities (both public and private), and national and provincial departments of health. With this money, Pakistan procured the equipment and medical supplies for the pandemic hit people.
Priorities and challenges of the Response Plan
The focus of Pakistan’s Humanitarian Response Plan for COVID-19 Pandemic 2020/National Action Plan is on saving lives and livelihoods of the estimated 5.6 million vulnerable people (until December 2020); setting priorities to contain the spread of corona virus; providing humanitarian assistance to those who need it the most, and; facilitate the running of the economy. Pakistan is finalizing its annual budget 2020-21 in which healthcare has been considered for the first time in its history as a top priority area. Before the COVID-19 pandemic, Pakistan used to spend around 2% of the GDP on the health sector, five times less than the global average of 10% spending on health.9 Amid the estimated loss of Rs 2.6 billion to the GDP growth due to COVID-19, the federal government has, in principle, agreed to give top priority to the health sector in the forthcoming budget 2020-21 despite tight conditionalities of the International Monetary Fund (IMF), including the elimination of indirect subsidies. The revenue collection as of June 30, 2020, is likely to be Rs 3908 billion against the original target of Rs 5500 billion. This is counted as one of the highest shortfalls in the revenue.10
The pandemic, despite its devastating impacts on people’s lives, livelihood, social interaction, relationships, movements, economy and businesses has brought an opportunity in terms of new thinking on prioritizing healthcare as the first defence line against an unknown and unseen enemy. Even before the COVID-19 pandemic broke in Pakistan, a large number of its population has been suffering from malaria, hepatitis and tuberculosis (TB), heart/hypertension, diabetes and other diseases. The Gallup report (11th edition) of the Pakistan Social and Living Standards Measurement Survey 2018-19 says that 4.2 million (2%) of Pakistanis reported that they had faced malaria in the past year and got treatment in one or the other form. The cases of hepatitis tested 6.4 million (3%) last year, while 25.5 million (8%) people say they got some precautionary measures against the disease. Similarly, 2.1 million (1%) people were tested for TB in the past year. Among them, 819000 (39%) were those who were re-infected past year from the previous year because they did not take any treatment. The surprising data is that 74 million people (35%) did not have any idea how TB is transmitted and 57 million people in the country do not know that TB is a treatable disease.11
The health sector profile of Pakistan is worrisome that is why the governments (federal and provincial) are contemplating the prioritizing of health in the budget as they have seen that COVID-19 has exposed the weaknesses of the healthcare systems and structures in the country. The Prime Minister Imran Khan’s government upon assuming power in the country, raised the cost of healthcare services at the public sector health facilities (hospitals) which were cheaper in the previous governments of both Prime Minister Nawaz Sharif of PML-N and Prime Minister Yousaf Raza Gillani of the PPP. This action was taken by the government to cut health expenditures for the public sector healthcare structures, which has led to further cost escalation at private health facilities. But now COVID-19 must make federal government and other PTI governments in Punjab and Khyber Pukhtoonkhwa rethink of their previous approach towards healthcare spending.
The three biggest challenges for the government are; a) to ensure equal and adequate access of the people to healthcare facilities and services, b) to ensure social, economic and livelihood protection amid growing unemployment and loss of livelihoods because of social distancing and lockdowns, and c) how to make sure that people observe SoPs while coming out of homes maintaining distance and using masks and sanitizers. The solutions to these challenges are interwoven and interconnected depending upon the implementation of the measures suggested to address these challenges.
Since COVID-19 is infecting all citizens irrespective of their social or economic status, ensuring access to testing and then isolation facilities if tested positive and provision of ventilators for those who enter the critical stage need appropriate actions now. The way the spread is increasing, hospital beds in ICUs with or without ventilators and beds in isolation wards are becoming scarce. If this trend continues, then, the health system both in public and private hospitals will be chocked. If the government has opened up some sectors of the economy to benefit the merchants and consumers, then both should observe the SoPs- ‘No Mask No Service’ policy, use of hand sanitizers and maintaining social distancing. If people do not observe SoPs, and infection spreads, it will lead toward a stern action by the government in terms of imposing a complete curfew/lockdown which will not be in the interest of small and medium sectors of economy. If this vicious cycle continues, the poor will be 10 times more vulnerable to the corona virus than those who are working from home and belong to the middle or affluent classes. This is the time when the people have to decide between their lives and livelihoods and their carefree, casual and non-serious attitude towards COVID-19.
AUTHOR
Shafqat Munir is a Research Fellow/Director, Resilient Development Programme, Sustainable Development Policy Institute (SDPI), Pakistan
Disclaimer: The views and opinions expressed in this article are those of the author/s and do not necessarily reflect the official policy or position of Azim Premji University or Foundation.
