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• 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.

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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

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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.

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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

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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.

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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.

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COVID ‐19 pandemic control and administrative issues in Pakistan: How Pakistan mitigated both pandemic and administration issues?

Muhammad ahsan ali raza.

1 School of Economics and Management, Beijing University of Posts and Telecommunications, Beijing China

Hafiz Syed Mohsin Abbas

2 College of Public Administration, Huazhong University of Science and Technology (HUST) Main Campus, Wuhan China

3 School of Management, Huazhong University of Science and Technology (HUST) Main Campus, Wuhan China

Associated Data

The data that support the findings of this study are available from the corresponding author upon reasonable request.

COVID‐19 is wreaking havoc all around the globe, and Pakistan bears no exception. This study explores Pakistan's response toward controlling COVID‐19 Pandemic from the day the 1st case was reported, February 26, 2020, in Pakistan until August 31, 2020. It explores the administrative conflicts among federal and provincial governments and political behaviors of political parties toward the COVID‐19 pandemic by referring Government Response Index. By applying the ARDL model approach, results show that since the administrative harmony had been implemented in Pakistan in July 2020, its positive impact on combating the COVID‐19 situation in Pakistan and substantial improvement in recovered cases and a downward trend new confirmed and fatal cases has observed in Pakistan. The findings demonstrate that administrative efforts scattered due to internal conflicts from February to mid‐July 2020 have ended, and collective aggressive policy enforcement has been mitigating the adverse impact of COVID‐19 in Pakistan since July to date. However, sustainable measures and prudent policy implications are needed to combat the ongoing COVID‐19 pandemic and future calamities.

1. INTRODUCTION

When nations were welcoming 2020, an uninvited and unexpected calamity called COVID‐19 also appeared. A group of coronaviruses spread like a pandemic and engulfed the entire world in no time (Abbas, Xu, Sun, Ullah, et al.,  2021a ; Shim et al.,  2020 ). Expecting that developing countries ought to face this pandemic's wrath the most, the actual situation was quite the opposite. Since this pandemic outbreak from Wuhan City of China on December 27, 2019, till today, China's fight against this problem was remarkable and appreciable. On the other hand, developed countries like United States, United Kingdom, Italy, France, and Spain have collapsed utterly in battling against this pandemic socially, economically, and psychologically (Mamun & Ullah,  2020 ; Moghanibashi‐Mansourieh,  2020 ). Moreover, along with economic and social, world has also been facing climatic, energy shortage and development issues since the COVID‐19 outbreak (Hoang et al.,  2021 ; Le et al.,  2020 ; Nguyen et al.,  2021 ; Ullah, Pinglu, Ullah, & Elahi,  2021 ). The COVID‐19 cases' situation is somehow better in developing countries; however, governance and response system issues ripped those countries to exposure, making the problem worse.

COVID‐19 is wreaking havoc all around the globe, and Pakistan bears no exception. Pakistan is a developing country with a lower‐middle‐income category than the World Bank database (World Bank,  2020 ). However, since its inception, Pakistan has been facing economic deprivation, health, and socio‐economic crisis precisely (Aslam,  2020 ). Aged 73 years, Pakistan did not have much significant political stability and state agility in any socio‐economic and governance indicators (Saqlain et al.,  2020 ). These factors are critical to every country's success, providing economic and social freedom and public well‐being toward its masses. These variables did not show much progress in every elected government because of internal conflicts and external and other economic and non‐economic factors, which becomes a more cause of economic deprivation in Pakistan. Political instability, political and ethnic conflicts are the biggest hurdles of Pakistan's development. These conflicts and uncertainty are the consequences of bipartisan political regimes, federalism, devolution, and institutional corruption. It can be analyzed that until 2019, Pakistan has not been stable in terms of its political and internal encounters. Due to corruption and poor institutional governance, there is a lack of public confidence in the government (Muçollari,  2018 ).

This study has examined the current COVID‐19 pandemic in Pakistan and its federal and provincial governments' conflicts toward a policy implementation in tackling this problem using the Government Response Index ( Ashraf,  2020 ; Hale et al.,  2020 ). Nowadays, it is a worldwide hot debate about tackling this problem and eradicating it ultimately. Pakistan introduced this problem in late February 2020, and it has been showing an increasing trend throughout the country. Federal and provincial governments are trying to mitigate its effects and running various public service campaigns to create awareness among the general public; however, the results are still not promising (Abbas, Xu, & Sun,  2021b , 2021c ).

This study attempted to explore Pakistan's response system's gray area, resulting in the further spread of COVID‐19, as suggested by (Abbas, Xu, & Sun,  2021b , 2021c ). It further analyzed that administrative conflicts and weak health response systems made the country vulnerable to current potential health crises. In the past, dengue fever spread in Pakistan is also one example of an inadequate health response system. Although the situation is somewhat better in Pakistan regarding COVID‐19 cases than in other regional countries, it can worsen if effective strategies and action plans will not be implemented in the coming days (Ullah, Pinglu, Ullah, & Elahi,  2021 ; Ullah, Pinglu, Ullah, & Hashmi,  2021 ). This study attempted to examine the situation of administrative conflicts that hike the pandemic cases; however, this study gives an insight into this situation and provides a thought of provoking the government to affect their disputes to the state adversely. They should control the administrative conflicts and instability to draft effective public policies for future causalities.

2. RESEARCH BACKGROUND

Since its inception, Pakistan has had different government styles, that is, democratic, autocratic, military, and bureaucratic (Aslam,  2020 ). Nevertheless, it failed to achieve its political stability in all regimes. The leading cause of this hardship is the tug of war for the command, that is, between federal and provincial administrations for policy implications. Affirmatively, Pakistan has been facing many likewise issues on which weak policy enforcement is observed due to this riddle of command and rule. On the other hand, a bipartisan political government makes public policy enforcement most unpleasant.

Public policy and political experts explained federalism as a governance model where the federal government coordinates and interconnects with the regional government and decisions (Dikshit,  1971 ). It further analyzed that this interconnection helps the government to useful policy implications across the country (Kincaid & Cole,  2002 ) and enhance the public institutional capabilities accordingly (Daumal,  2008 ; Lane & Ersson,  2005 ). Moreover, federalism helps to synchronize the institutions for the equal or appropriate distribution of resources among the regions, revitalizing public institutions' outcomes in efficient manners without conflicts (Weingast,  2009 ). Federalism, along with national unity and harmony, also supports the governments to make healthy and productive international relations and treaties (Fisher,  2015 ) that lead to economic growth in developing countries (Baskaran et al.,  2016 ), which has been surveyed and experienced by the public policy scholars (Marlin,  2016 ). Although federalism significantly impacts decision‐making, no matter whether partisan or bipartisan political allies support the government. However, it also examined that it can create a conflict of interest among policymakers that intimate the shredding of political powers (Martin & Vanberg,  2020 ). Moreover, this friction or conflicts of interest in bipartisan political ideologies leads to inefficiency in policymaking (Abbas, Gillani, et al.,  2020 ; Abbas, Xu, et al.,  2020 ; Chan & Fan,  2020 ).

In terms of ideologies and political concerns, friction gives birth to other contrasting terminologies in political and public administration studies: Federalization and devolution. These terms describe the delegation of administrative strategies and later for political authorities for autonomous decision making (Bresser‐Pereira, 2004). As some scholars supported federalism for decision making, others support devolution for economic growth at the regional level, where federalism cannot resolve the policy disputes (Balint & Mashinya,  2006 ; Hudson,  2006 ). However, scholars also have some cultural and regional concerns for devolution and do not fully support it (Rose & Miller,  2010 ; Tsukamoto,  2011 ). It further analyzed that devolution enhances ethnic and religious bonding; on the other hand, it arouses institutional corruption or misuse of powers if weakly controlled (Carlucci et al.,  2017 ; Pozdena,  2018 ). However, in recent studies, it is also explored that devolution supports regional progress by taking demographic, social, health, and regional challenges and liaison with the federal government in policy implications, especially in developing and populated countries (Chan & Fan,  2020 ; Gaisie et al.,  2019 ).

2.1. Pakistan and structure of government

Since its inception 73 years ago, Pakistan has struggled for democratic and exemplary leadership (Asghar,  2013 ; Aslam,  2020 ). Pakistan comprises four provinces (Punjab, Sindh, Khyber Pakhtunkhwa, and Balochistan) and three special administrative regions (Islamabad Capital Territory, Azad Jammu and Kashmir, and Gilgit Baltistan). At the same time, the President is head of state, and Prime Minister is the head of government. Moreover, more than a dozen political parties are working in Pakistan. However, among them, four are prominent, that is, Pakistan Tehreek‐e‐Insaf (PT1), Pakistan Muslim League‐Nawaz (PML‐N), Pakistan's People Party (PPP), Pakistan Muslim League‐Quaid‐e‐Azam (PML‐Q), and Jamat‐e‐Islami Pakistan (JIP). Several parties worsen as everyone has their own political and national agenda for running the state (Martin & Vanberg,  2020 ).

This multiparty battle for the ruling has significantly impacted Pakistan's stability and progress. Pakistan has been facing a tug of political war for many years between federal and provincial governing. Especially since the announcement of the transformational devolution plan in 2000 for the precision of the federal and provincial government's rules of responsibilities (Ahmad & Akif,  2007 ). It further empirically analyzed that this plan or reform significantly impacted the institutional quality for public services outcomes, resulting from coordination among federal and provincial governments (Agranoff,  2011 ; Aslam & Yilmaz,  2011 ). It further explored that devolution or delegation of political power will help construct a strong constitution of Pakistan and develop a robust regional bonding among provinces (Myerson,  2014 ). However, some issues originate in its transition period (Lind,  2018 ), which needs to resolve with a healthy leadership system (Ahrens et al.,  2020 ).

2.2. Pakistan response in health outbreaks

Being a developing country, Pakistan has been facing many socio‐economic and health crises in the past, that is, earthquake 2005, flood 2010, dengue fever 2011, and recent COVID‐19. World Health Organization has issued Pakistan's operational guidelines as an early disease warning system for health systems' preparedness from any uncertain epidemic (WHO,  2010 ). These programs address the danger of virus issues in developing countries, for example, dengue fever, SARS, MEARS, and other virus issues. The dengue fever epidemic affected more than 50,000 people, with more than 300 deaths in different periods in 2011, 2015, 2017, and 2019 in Pakistan (WHO,  2019b ). Although this virus affected Pakistan as a pandemic a couple of years ago, earlier than 2011, it never turned into an epidemic. It further analyzed that emerging infectious viral attacks are the most deadly in developing countries (Bakhsh et al.,  2018 ; Khalil et al.,  2017 ; Zubair et al.,  2016 ). The dengue epidemic is linked with environmental changes and mainly outbreaks in the summer season due to mosquito biting; that is why proper awareness and early response system needs to be activated before it happens (Bakhsh et al.,  2018 ). However, the development of a dengue emergency response committee, closure of Educational institutes, and imposed article 144 in the country was taken as preventive measures to mitigate its effects and control the situation.

As per the United States Centre for Disease Control and Prevention (CDC), most deaths occur in Pakistan due to virus‐related diseases. In 2020, a novel coronavirus (COVID‐19) pandemic was challenging and exposing Pakistan's response system (Faisal,  2020 ). COVID‐19 has produced a global panic and chaos situation among public and health professionals since December 31, 2019, due to its unique contagious characteristics, making it challenging to track and control (Xiao,  2020 ). As per the Ministry of National Health Services Pakistan (NHS) and John Hopkins University Corona Resource Centre, as of August 31, 2020, more than 25,486,747 patients globally and 296,170 locally have been affected in Pakistan, although it hit Pakistan on February 26, 2020. As per the studies, Pakistan had to be vigilant because the response was not as quick as it would be (Nafees & Khan,  2020 ). So far, Pakistan does not have adequate measures and facilities (Quarantines and Isolations centers), making it unable to cope with this situation (Abbas et al., 2021b; Waris et al.,  2020 ).

3. METHODOLOGY

This study has empirically analyzed the daily updates of all cases of the COVID‐19 pandemic in Pakistan and government responses. The federal and provincial governments have implemented lockdown strategies, and social distancing awareness as control or mitigating measures has been taken under discussion that supported the results. The COVID‐19 pandemic updates have taken from the Health Advisory Platform (HAP), 1 an initiative by the Government of Pakistan (GOP), Humanitarian Data Exchange, 2 World Health Organization, and time Horizon considered from the first date of the COVID‐19 outbreak in Pakistan on February 26, 2020, to August 31, 2020.

Furthermore, data regarding Pakistan's Health facilities were collected from Economic surveys of Pakistan—Ministry of Finance, Pakistan, and Pakistan Bureau of Statistics, and the time horizon for these data are the financial years 2008 to 2018 or (last updated). A newly developed Government Response Index by the University of Oxford Research group 3 examined the government policy (stringencies, socio‐economic support to masses, and emergency health investment) toward COVID‐19 worldwide and ranges value (0–100, on the scale of weak to strictest policy implementation) from January 01, 2020, to date (Abbas et al., 2021b; Hale et al.,  2020 ). Further, later data was discussed to assess Pakistan's health care response system and the government's strategies for controlling COVID‐19 analysis at a federal and provincial level in Pakistan. In a nutshell, this study has applied the mixed approach of descriptive, theoretical, and empirical estimations to make this study comprehensive and novel concerning Pakistan and its battle to COVID‐19.

3.1. Empirical estimations

This study applied the auto regressive distributed lag (ARDL) co‐integration approach (Pesaran et al.,  1999 , 2001 ). In recent studies, researchers analyzed that due to the co‐integration approach ARDL model is one of the most common dynamic unrestricted modes used in ARDL literature nowadays (Ghouse et al.,  2018 ). In further studies, scholars identified in a long and short‐run analysis that autoregressive distributed lag model (ADRL) is suitable for taking appropriate Lags numbers, which help capture correlation in co‐integration variables (Shrestha & Bhatta,  2018 ). In an ARDL model, two‐step rooted in a long‐run analysis; first, identify the long‐run and second estimation of co‐efficient in the long‐run and short‐run in the same equation (McCann et al.,  2010 ; Sulaiman et al.,  2019 ). In a more profound analysis, this study applied robustness tests; Durbin–Watson test and Breusch–Godfrey test for identifying the serial correlation and no correlation, Breusch–Pagan, and LM ARCH Tests to check the heteroscedasticity and Ramsey RESET Test for specification are the critical testing tactics for ARDL (Shrestha & Bhatta,  2018 ).

Model 1 equations equation can be written as follows;

Model 2 equations equation can be written as follows;

Model 3 equations equation can be written as follows;

where NCC represents new confirmed cases, RC indicates recovered cases, and DC is the deaths indicator. While GRI represents the Government Response Index. Apart from that, B 0 is the constant value, whereas μ serves as an error term. Cross‐sectional units are detonated by subscript i and t denoted time.

3.2. Research framework

Based on the above literature and Pakistan's current situation toward political decision‐making and conflicts, this study draws a conceptual research framework, Figure  1 , to describe the federalism and devolution organizational conflicts in Pakistan. This framework demonstrates the current scenario of organizational conflicts in Pakistan toward public policy implementations. It shows that due to a difference of opinion in decision making of federal and provincial governments get ineffective outcomes. Simultaneously, political harmony and unity toward policy implementation and enforcement get effective and fruitful results.

Conceptual framework. Source : Authors estimation

As per the public institutional quality rating by world development indicators, international country risk guide, and quality of government institutes, Pakistan has faced these administrative conflicts obstacles in policy effectiveness and political stability. In the recent studies of Hayat ( 2019 ), Nafees and Khan ( 2020 ) examined that Pakistan is politically unstable due to internal politics more than external factors and threats, which raised the ineffectiveness toward policy implementations.

4. DATA FINDINGS AND DISCUSSION

4.1. data analysis.

Tables A1 and A2 demonstrate health care facilities in Pan Pakistan and provincial breakup, that is, no of hospitals, doctors, nurses, hospital beds, and Pakistan's health expenditures. It has shown that doctors and the para‐medical situation show improvement with population growth with time; however, hospital beds and healthcare expenditures do not show much progress in this context. Appendix A3 illustrates the 2018–2019 and 2019–2020 total budgets and Pakistan's provincial budget situation in health and research and development.

4.2. COVID ‐19 analysis in Pakistan

This section, through tabular and graphic, analyses the COVID‐19 trends within Pakistan. With and by applying the inadequate resources mentioned in Tables A1–A3, the Pakistan government has been battling with the COVID‐19 pandemic. The below review used the dashboard data of COVID‐19 as quantitative and lockdown enforcement as a qualitative mixed approach to evaluate Pakistan's situation.

COVID‐19 pandemic first struck Pakistan on February 26, 2020, when two cases were tested positive in Pakistan's Sindh province. After that, it has been spreading across Pakistan. Figure  2 shows the updated situation in Pakistan. So far, 296,149 confirmed cases, 6298 deaths, and 280,970 recovered cases have already been reported in Pakistan in 6 months battle against the COVID‐19 pandemic. As per the updated trend, Pakistan's situation has been improving compared to the months ago.

Daily COVID‐19 situation in Pakistan. Source : Humanitarian Data Exchanges sponsored by John Hopkins University USA, National Health Services, Pakistan and University of Oxford COVID‐19 Project

However, the Government Response Index trend explained that the government policies toward the closure of vulnerable areas and institutes, government support to the economic sector, and investment in the emergency health sector and vaccine development have not been practical in controlling the COVID‐19 situation in Pakistan. In the initial days, with the immediate closure of the state's economic and social cycle, cases were on the low side; however, as the government relaxed its stringency policies situation had been horrifying. The overall scores show that the Government Response Index negatively correlated with COVID‐19 cases (Ashraf,  2020 ). Hence, as the COVID‐19 has been devastating worldwide same and Pakistan bears no exception. From the start of July 2020 to date, COVID‐19 and government policies show a strong positive correlation, which is a positive sign toward the resumption of the country's social, economic, and psychological aspects.

It was observed that in the 6 months of the pandemic in Pakistan, confirmed infected cases are 1575, deaths were 34, and recovered cases were 1495 per day. Furthermore, it shows that in August 2020, recovered patients showed significant improving trends (in the red squared area) in Figure  2 , compared to confirm and instances of death. However, initially, the government could not tackle the situation just like the rest of the world.

As per the current constitution arrangement of Pakistan's health system, the provincial government is accountable for providing health in the respective region, and the federal health ministry plays only a governing and policy implications role. Owing to this arrangement, the provincial response toward controlling the COVID‐19 is crucial in this discussion. As per Tables  4 and ​ and5, 5 , Sindh is the second most populous region and comprises more than 22% of Pakistan's population. However, it shows more confirmed cases, around 44% of 296,149 patients across the country. A confirmed case and recovered cases indifference trend to Pakistan's population has been observed in Punjab, Sindh, Khyber‐Pakhtunkhwa, Balochistan, and Azad Jammu Kashmir.

Descriptive statistics

Source : Authors Estimation.

Correlation matrix

Note : * p  < 0.05, ** p  < 0.01, *** p  < 0.001.

However, Punjab and Sindh, the most populous regions, were affected the most due to COVID‐19. In Punjab, 96,832 cases, the death rate is 2.27%, and the recovery rate is 95.53%, while Sindh showed approximately 44% cases overall with 129,469 patients, and its death rate the recovery rate is 1.86% and 95.06%. The situation is observed in KPK, Where the fatality rate is 3.46%, and the recovery rate is 94.07% in its 36,118 cases. Simultaneously, KPK suffered from the most deaths to the confirmed case ratio so far, and the KPK, Punjab, Azad & Jammu Kashmir, and Gilgit Baltistan's fatality rates are higher the overall Pakistan fatality rate, that is, 2.13%.

4.3. Discussion on Pakistan health emergency arrangement

COVID‐19 struck Pakistan on February 26, 2020; however, the government has prepared no action or proactive strategy. Soon after, the National Command and Control Authority (NCCA), headed by the Military, took charge of emergency arraignment in Pakistan. International travelers' screened at airports; however, no adequate or satisfactory measures have been observed, and resultantly after 3 weeks till late march, more than 750 cases were tested positive in Pakistan. World Health Organization stated that imported transmitted cases became the host of the COVID‐19 in Pakistan. NCCA also confirmed that 42% are those in Pakistan who had returned from foreign countries, and due to inappropriate airport screening, restrictions, and borderlines with Iran and Afghanistan, these numbers multiplied, spreading the COVID‐19 across the country with 58% cases locally transmitted. Currently, federal and provincial governments are trying to make efforts at best to overcome this pandemic.

Table  2 demonstrates the health emergency arrangement by the government of Pakistan across the country. In total, 35 hospitals were designated for the COVID‐19 treatment with a 2942 bed capacity in 215 isolation across the country. Balochistan (Taftan) shares the border with Iran, which became the epicenter of this pandemic in Pakistan as it allocated more quarantined bed facilities 5897 for Zaireen (pilgrims from Iran). These Zaireen were placed at a quarantine facility if tested positive. Table  2 depicted that testing labs are inadequate in Pakistan, along with that testing kits are insufficient to tackle this situation. As of June 10, 2020, daily testing capacity (including public, private, and military hospitals) has increased in Pakistan across the country to 45,830 per day. As of August 31, 2020, 2,621,146 persons 4 have been tested so far in Pakistan in 216 million population with 12,134 tests conducted per million population with an average of 14,323 tests per day in 188 days. These official statistics reveal that only 1.21% of the population has been tested yet in Pakistan, and the infected outcome is 11.30%.

Province wise health emergency arrangement by government of Pakistan

Source : National Health Services, Pakistan last updated August 31, 2020.

It was observed that the COVID‐19 is spreading its fear across the globe, including Pakistan. Being a developing country and politically unstable, it is a matter of concern about how Pakistan will cope with this situation. First officially locked‐down and a preventative policy enforced into Pakistan by the Sindh Provincial Government followed by the Punjab Government and rest of the provinces on March 24, 2020. It analyzed that till March 23, 784 confirmed cases and five deaths have already occurred across the country. As per Tables  1 and ​ and3 3 confirmed cases, Pakistan's death rate is much worse than its regional countries, e.g., China, Iran, and India, from the first date reported until August 31, 2020. However, Pakistan's delayed health response system came into action (Nafees & Khan,  2020 ). The health system in Pakistan under devolution (Ahmad & Akif,  2007 ; Aslam & Yilmaz,  2011 ) and their policy and preventive strategies also differ. That shows the indifference trend in adopting preventive measures and reflects the inadequate remedial measures to tacking the situation (Waris et al.,  2020 ).

Provincial share of COVID‐19 situation

Source : Authors Estimation. National Health Services, Pakistan (Data Compiled) last updated August 31, 2020.

Partial lockdown enforcement conflicts and impacts on the COVID‐19 situation in Pakistan

Source : National Health Services, Pakistan and Authors Estimation.

It has witnessed an unprecedented situation in Pakistan regarding austerity measures to tackle the condition 5 ; however, decision‐making was delayed. Its shows that governments are not following the international agencies recommendation and guidelines for its health response systems. WHO issued guidelines for Pakistan (WHO,  2010 ), an emergency health action plan (WHO,  2019a ) globally, as well as European Union made an epidemic response system (Antofie et al.,  2018 ) to tacking such a situation. Unfortunately, both were ignored in policy drafting; otherwise, the condition would not have been this painful. An article in Harvard Business School on March 27, 2020, criticized the global health response against the COVID‐19, stating the world had not learned the experience of China, South Korea, Italy, and Iran.

It was observed that the difference of opinion and conflicts of opening the border with Iran between federal and provincial governments also ignited the heat among policymakers and institutions. Flight operations and industry closure have also been controversial. Despite social media awareness on social distancing, the government was unable to implement the lockdown completely. On April 15, 2020, the federal government relaxed lockdown for low risk and some other industries, which started the new debates among local governments; the Sindh government criticized the federal government's decision while new cases and deaths increased in Pakistan. Another conflict was observed on May 1, 2020, where the federal government gave further relaxation in lockdown across the country in the construction sector and religious institutions; conversely, the Sindh government tightened its lockdown measures and restricted the people at homes. A blame game of the rising trend of the COVID‐19 increasing trend observes between the Sindh government and federal government (the same political party rules Punjab, Balochistan, and KPK provinces). However, no one is taking ownership of this worst situation; neither can enforce social distancing and preventative measures in the appropriate manners. Unfortunately, the federal and Provincial governments have failed to engage the public toward adopting preventive measures due to its internal administrative conflicts.

As of July 15, 2020, federal and provincial governments proposed the two‐week complete lockdown across the country, but Sindh province refused this proposal and continues the partial lockdown and extended the tighten policy enforcement toward preventative measures. Sadly, these conflicting outcomes showed that policies have been ineffective yet regarding COVID‐19 cases, which shows that policies lack effectiveness, as depicted in Table  3 . However, for future policy measures, the government should consider the stringent guidelines by assuming socio‐economic crises to control the COVID‐19 trend and make a comprehensive policy to cater to future unforeseen calamities (Ashraf,  2020 ), and educate the public in a better way to adopt social distancing and other precautionary measures (Shim et al.,  2020 ).

Table  3 depicted that government policy implementation has remained ineffective throughout the pandemic until the end of July 2020, mainly since May to July was the crucial time for Pakistan. Although the government response index shows a much higher value, the Government Response Index are stringency, socioeconomic, and health containment policies. Even by the imposed high degree of lockdown, health emergency measures, and economic support to the business sector, internal administrative conflicts and religious conflicts with socio‐economic crises hinder policy effectiveness. As per the International Country Risk Guide (2019), Pakistan has faced a high degree of political, religious, and ethnic conflicts, obstructing ineffective policy implementation. During the COVID‐19 pandemic, the same political and administrative battle has been witnessed among federal and provincial governments by implying lockdown, socio‐economic and health policies, and the resulting hike of COVID‐19 situation observed in Pakistan.

As Figure  2 illustrated, the more precise picture of policy implementation and its effectiveness. It depicted that the government's inconsistent policy implementation and relaxation in lockdown policies raise the cases of COVID‐19 and still have been relaxing the policy terms. On the other hand, it depicted that increasing the testing capacity government has not diagnosed enough people. It also happened due to the misallocation of health resources in the health sector. Sindh province has not been equipped enough compared to its population ratio due to administrative conflicts between federal and Sindh provincial governments. However, by administrative harmony and unity, a better picture has been depicting on controlling the COVID‐19 situation in Pakistan since July to date (Ayub,  2020 ; Abbas et al., 2021b).

4.4. Results of descriptive and autoregressive distributed lag model statistics

Table  4 demonstrates the descriptive statistics of the data selected from February 26, 2020, to August 31, 2020.

Table  5 depicts the correlation matric of one independent variable, GRI, and three dependent variables NCC, DC, and RC. Results show that NCC and DC are positively correlated with GRI, while RC is negatively correlated with GRI. The analysis shows that with time, relaxation in policy implications in Pakistan has been observed. A high degree of policy enforcement but interval political conflict had a low positive impact on controlling the COVID‐19 situation in Pakistan in a more profound analysis. However, even to a low degree, internal harmony and joint aggressive policy enforcement positively impact combating the COVID‐19 crisis in Pakistan and hike the recovered cases, negatively correlating with the government response index.

By applying the ARDL approach in Table  6 , results show that GRI has a more significant impact on recovered cases of COVID‐19 in Pakistan with a 99% confidence interval at the Lag length 1. At the contract, NCC and DC show their significance with a 99% confidence interval at Lag length 3 and Lag 2, which indicates that GRI has a substantial impact on Pakistan's recovery situation. Findings suggest that based on enforcement policy confrontations, health containment efforts have been more efficient and positively impacted combating COVID‐19. Health policy implementations on recovery cases show a positive trend with an R ‐square value of 0.2157. While a considerable positive impact on controlling and decreasing trend has been observing in NCC and DC in Pakistan with R square value 0.7998 and 0.7583 which indicates that new infection and fatality of COVID‐19 has remained highly under controlled period due to massive spread situation in all over the world and aggressive policymaking in Pakistan after the initial 04 months of pandemic battle. Detailed ARDL results are demonstrated in Table  6 .

ARDL regression analysis

Note : t Statistics in parentheses, * p  < 0.05, ** p  < 0.01, *** p  < 0.001.

Abbreviations: ARDL, autoregressive distributed lag model; GRI, Government Response Index.

4.5. Robustness/diagnostic tests

Table  7 demonstrates the Long and Short Run relationship of the COVID‐19 indicators and GRI situation in Pakistan, which indicates that in the long‐run overall impact of policy enforcement has a more substantial impact on Pakistan in its initial 6 months battle. However, in the short run, the policy was not effective at all, and the COVID‐19 situation had worrisome.

Long and short run relationship

Abbreviation: GRI, Government Response Index.

ARDL bound test shows the Cointegrating of the data in Table B1. In checking the robustness and autocorrelation in the data, the Durbin–Watson test, heteroscedasticity, Breusch–Pagan, Breusch–Godfrey LM, and Ramsey RESET test estimated showed in Tables B2–B4. A value of 1–2 shows a positive autocorrelation in robustness analysis, while 2–4 depicts a negative autocorrelation. The study results show a negative correlation or no correlation present in the data with values 2.038233 and 0.000, respectively. Another robustness analysis has run in STATA: Breusch–Pagan/Cook–Weisberg test and Lagrange Multiplier autoregressive conditional heteroskedasticity (LM ARCH) test to check the heteroskedasticity (refers to the error variance, or dependence of scattering, within a minimum of one independent variable within a particular sample) in data, In Breusch–Pagan and LM ARCH tests, the p ‐value of chi should be below 0.05 to reject the heteroskedasticity. The result shows a p ‐value chi is 0.0435, which denotes that the null hypothesis of heteroskedasticity is rejected and heteroskedasticity is expected, and no arch effect is observed in data. Another diagnostic analysis was run by applying the Ramsey RESET test to check the linear regression model specification. Its value should be from 0 to 1, which shows no omitted variables and depicts a non‐linear combination of the response's fitted values variable.

5. CONCLUSION AND POLICY IMPLICATIONS

This study analyzed the COVID‐19 situation in Pakistan in the background of conflicts between federal and provincial governments in coping with this pandemic. Moreover, the government response index and COVID‐19 NDR (new confirmed, death, and recovered) cases have been taken under analysis. As per world governance indicators issued by The World Bank, the Internal Country Risk Guide and Quality of Government Institute shows that compelling Policy implications and regional administrative conflicts have remained a problem in Pakistan, which are also observed in the current COVID‐19 pandemic. It has been summarized that differences between federal and provincial governments make the situation worse by analyzing the statistical data. It examined that the federal government's initial reluctance on lockdown, which provincial governments opposed, also contributed to the rise in the number of new COVID‐19 cases in Pakistan. Furthermore, for more profound and prudent policymaking, the Federal Government of Pakistan should bring all stakeholders on board so that one united message is conveyed to all regarding getting the COVID‐19 situation under control and making a sound strategy to cater to future calamities.

The results show that since the administrative harmony had been implemented in Pakistan in July 2020, it positively impacts combating the COVID‐19 situation in Pakistan and substantial improvement in recovered cases and a downward trend in new confirmed and fatal cases observed in Pakistan. The findings demonstrate that administrative efforts scattered due to internal administrative conflicts from February to mid‐July 2020 have ended, and collective aggressive policy enforcement has been mitigating the adverse impact of COVID‐19 in Pakistan since July to date. It concludes that, for more profound and prudent policymaking, the Federal Government of Pakistan should bring all stakeholders on board so that one united message is conveyed to all regarding how to get the COVID‐19 situation under control and make a sound strategy to future calamities.

COVID‐19 is affecting the world at an increasing rate with each passing day. As of August 31, 2020, 25,486,747 cases of the COVID‐19 have been reported worldwide. Like any other country, Pakistan has also taken many measures to control this pandemic. Initially, the situation in Pakistan remained better as compared to other regional countries. However, it started to get worse quickly. Primarily because of the differences in policy implications between federal and provincial governments. The authorities estimate to have more COVID‐19 positive patients by the end of the third quarter of 2020 with the second wave of COVID‐19 if proper precautionary measures will not be taken seriously. However, as per the updated trend in July 2020, the situation of the COVID‐19 is getting better in Pakistan compared to a few months ago, and the daily recovery rate is increasing and getting higher than in new cases. Furthermore, this happens because of deferral and provincial government same page initiatives with standard operating procedures toward COVID‐19 policy implications, lacking in the initial days.

Similarly, the federal government's decision to partially open up industries and businesses after the partial lockdown is also opposed by the Sindh provincial government. These differences have rendered the policy implementation regarding the COVID‐19 ineffective. Moreover, Government Response Index denoted the policy inputs have been getting unfavorable outcomes until the end of June; however, the situation somehow improved from July to date. It is crucial for all stakeholders in Pakistan to join hands with each other and unanimously take policy decisions. Moreover, this paper suggests that all state institutions should avoid conflicting policies and take this pandemic to the front desk. All stakeholders, including religious and political scholars, should promote social distancing, a crucial preventive measure against the COVID‐19. When all the stakeholders convey a standard message, implementing policy decisions regarding the COVID‐19 will become much more effective in Pakistan as the country fought against measles, polio, and dengue in the past. Only in this way, the situation can bring under control. The fruitful administrative harmony is witnessed recently when The Economist issued a Global Normalcy Index 6 in May 2021 and ranked Pakistan third in 75 global economies with 75% population of the world and hold 95% global GDP. This index shows how the government of the respective government has made prudent and excellent administration to get economic activities back after deadly COVID‐19 waves. Moreover, a significant long‐term conflict management policy is a dire need in Pakistan's political system so that all political parties will work in emergencies as a unit and overcome the calamities.

5.1. Future research

This study focused on the civilian government's policy perspective on the COVID‐19 combating in Pakistan with empirical research due to limitations and updated policy measures. For future studies, the Military's role and the civilian government on the COVID‐19 pandemic can be analyzed. Furthermore, besides the authoritarian perceptive, attitude, and behavior of the general public toward complying with the guidelines and taking precautionary measures of the COVID‐19 will be an excellent perspective to investigate the COVID‐19 battling Pakistan. The impacts of the smart lockdown concept of Pakistan by partially lockdown the infected areas on controlling COVID‐19 will also be analyzed from a policy perspective. Further, for future studies, a sound policy can cater to future emergencies by using this administration scenario. In future studies, a comparative policy analysis of past and current epidemics/pandemics with their outcome will be an excellent approach to study, for example, dengue fever and COVID‐19.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

Biographies

Muhammad Ahsan Ali Raza  is a final year PhD Scholar at the School of Economics and Management, Beijing University of Posts and Telecommunications, Beijing, China. He has published more than 10 research papers in well‐reputed international journals as lead and co‐author. His area of interest is public management, risk management, public economics and finance.

Chen Yan  is a PhD professor and Dean of School of Economics and Management and Dean of International College, Beijing University of Posts and Telecommunications, Beijing, China. He has published plenty of academic papers, books and presented various papers in international conferences. His area of interest is international trade theory and practice, frontiers of international business management, international business.

Hafiz Syed Mohsin Abbas  is a PhD graduate from College of Public Administration in Huazhong University of Science and Technology, Wuhan P.R. China. He has published more than 16 research publication (SSCI/SCI/SCIE/ESCI) in well‐reputed journals with good impact factors. His area of interest is governance, public administration, institutional quality, public management and public policy, public services, sustainable development.

Atta Ullah  is a PhD scholar, School of Management, Institute of Poverty Reduction and Development, Huazhong University of Science and Technology (HUST), Wuhan, China. He has published more than 30 papers in renowned journals. Research interests in sustainable/green finance, sustainable development, multi‐dimensional regional integration, technology advancement in society, institutional quality, poverty alleviation, energy economics, monetary policy, financial stability, corporate governance, risk management, currency depreciation, belt and road countries.

Health care facilities in Pakistan since 2008–2018

Source : Authors Estimation. Ministry of Finance (MOF), Pakistan and Pakistan Bureau of Statistics (PBS).

Abbreviation: HCE, health care expenditures.

Province wise updated healthcare facilities in Pakistan

Source : * Pakistan Bureau of Statistics, Compendium Gender 2019 Report. **Pakistan Medical and Dental Council Statistics, 2019. ***Pakistan Nursing Council Statistics, 2019. ****A Special Administrative area under federal government.

State and provincial budget allocation in health and R&D in Pakistan

Source : Pakistan budget financial year 2019–2020 Ministry of Finance (MOF), Pakistan.

ARDL bound test analysis

Abbreviation: ARDL, autoregressive distributed lag model.

Robustness autocorrelation tests

Robustness heteroskedasticity tests

Ramsey RESET test of specification

Note : Specification: Ramsey RESET test using powers of the fitted values of NCC.

Abbreviation: GRI, Government Response Index; VIF, Variance Inflation Factor.

Raza, M. A. A. , Yan, C. , Abbas, H. S. M. , & Ullah, A. (2021). COVID‐19 pandemic control and administrative issues in Pakistan: How Pakistan mitigated both pandemic and administration issues? Journal of Public Affairs , e2760. 10.1002/pa.2760 [ PMC free article ] [ PubMed ] [ CrossRef ]

1 http://covid.gov.pk/stats/pakistan

2 https://data.humdata.org/dataset/novel-coronavirus-2019-ncov-cases

3 https://www.bsg.ox.ac.uk/research/research-projects/coronavirus-government-response-tracker

4 https://data.humdata.org/dataset/total-covid-19-tests-performed-by-country

5 Hina Sheikh, COVID‐19 Pakistan preparedness and response: https://www.theigc.org/blog/COVID-19-pakistans-preparations-and-response/

6 https://www.economist.com/graphic-detail/tracking-the-return-to-normalcy-after-covid-19

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The pandemic deals a blow to Pakistan’s democracy

Subscribe to the center for middle east policy newsletter, madiha afzal madiha afzal fellow - foreign policy , center for middle east policy , strobe talbott center for security, strategy, and technology , center for asia policy studies.

August 6, 2020

As Pakistan continues to deal with COVID-19 — with more than 280,000 cases to date and over 6,000 dead — in the face of a struggling economy, the pandemic is dealing a blow to its fledgling democracy. While Pakistan has brought new coronavirus cases and deaths under control in the past month, the pandemic’s aftershocks have weakened the country’s current civilian government, further emboldened its military, and brought about a broader crackdown on dissent.

The military steps into the “gap”

I, along with other analysts as well as public health experts, criticized Pakistani Prime Minister Imran Khan’s initial response to the coronavirus for being weak and indecisive . He refused to implement a nationwide lockdown, letting Pakistan’s four provinces implement their own lockdowns. The provincial actions limited the initial spread of the virus. Khan focused instead on a gimmicky coronavirus youth “Tiger Force” that would help the government disseminate its message. His government first caved in to the religious right to keep mosques open during Ramadan and then allowed markets to reopen too quickly toward the end of Ramadan in May, resulting in a spike of cases across the country in June, stretching its hospitals and doctors to the limit. Khan’s messaging during this time was muddled .

The country’s powerful military, reportedly unhappy both with Khan’s response and that it drew criticism, had publicly backed a tougher lockdown at the same time that Khan opposed it in March. It then started taking a more visible role in the coronavirus response. When the virus seemed to be spiraling out of control in June, the National Command and Operation Center (NCOC) — the joint civilian-military body created to coordinate the national COVID response, in which high-ranking military officers play increasingly visible roles, enforced “smart” lockdowns in hundreds of COVID hotspots across the country. The military’s intelligence agencies led in surveillance and contact tracing efforts. (Khan still chairs meetings of the National Coordination Committee, the decisionmaking arm of the NCOC, but the army chief General Qamar Bajwa also attends many of those meetings.)

As the military’s involvement has grown, the pandemic has been brought under control in the country — at least for now, with Pakistan on the other side of its first wave (see graphs below). The communications aspect of the pandemic response is certainly being managed better. Critics contend that the government is under-testing, thus making the picture appear rosier than it is, but case positivity rates in Pakistan — the proportion of positive cases among those who are tested — have also declined, suggesting that the situation really is improving. Though the causes behind the declining cases and deaths aren’t completely clear — even Khan acknowledged he was surprised by the speed of the decline — nor is it clear how long the decline will last, it seems the government’s strategy of “smart” hotspot lockdowns across the country, combined with keeping restaurants and large indoor venues (e.g. marriage halls) closed, has worked. (Khan has argued that this validates his approach against a blanket lockdown.)

Beyond former and current military men being highly visible on the COVID response — the executive director of Pakistan’s National Institute of Health is also a major general — Khan’s cabinet is increasingly populated by former military men. Retired Lieutenant General Asim Bajwa, a former head of the Inter Services Public Relations (the military’s public relations arm) and the current head of the China Pakistan Economic Corridor Authority, was appointed the prime minister’s new special assistant on information and broadcasting in April. There are other ways the military’s growing role in civilian affairs is visible: In June, it was Chief of Army Staff General Qamar Javed Bajwa, not Khan, who took a trip to Kabul and met with President Ashraf Ghani and chief negotiator Abdullah Abdullah on the Afghan peace process. General Qamar Bajwa is also U.S. Secretary of State Mike Pompeo’s main Pakistani interlocutor on the peace process.

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The military’s increasing control seems to be a response to the initial performance by Khan and his government on COVID. As a retired general told the Financial Times: “The government left a big gap in its handling of the coronavirus. The army has tried to fill that gap, there was no choice.” There were also several other factors at play: Khan’s apparent decline in popularity with the public, an exposé of a sugar industry scam, fissures within Khan’s party’s ranks, and the fracturing of his weak coalition in parliament. Pakistan’s military used similar excuses in the past to destabilize democratically-elected governments behind the scenes. The cycle is repeating yet again.

A “minus-one” formula

In June, rumors began to float in Islamabad that Khan’s hold on power was precarious and he might not last much longer as prime minister. He took to the floor of the National Assembly to address the rumors in a long, rambling speech on his government’s performance. Khan even brought up the opposition’s call for a “minus-one” formula: the idea that he should step down to pacify opposition parties while his government finishes out its term. That is essentially how former Prime Minister Nawaz Sharif’s party survived its term in government — without Nawaz. In his speech, Khan insisted that he would finish his term.

Khan’s strident tactics in the past as an opposition politician haven’t helped him now that he’s in power, in terms of dealing with the current opposition. During a sit-in that lasted for weeks in 2014, Khan clamored for Nawaz Sharif’s ouster every night while standing on a shipping container, and some say he is reaping what he sowed. But part of the problem is also the structure of civilian-military relations in Pakistan: Pakistan’s powerful military relies on performance legitimacy for itself, but also for civilian governments, and quickly loses patience with them once their performance falters. The military does not wait for the civilians to be voted out but progressively asserts control, or pushes for their ouster, as it did in the 1990s, destabilizing Pakistan’s entire democratic enterprise. In this playbook, opposition parties often work as pawns for the military, willing to go beyond parliament — such as with “multi-party conferences” or back-room deals — to destabilize the incumbent government. In recent weeks, the current opposition parties, the Pakistan Muslim League-Nawaz (PML-N) and the Pakistan People’s Party (PPP), have fit right into those prescribed roles. The public, too, has become accustomed to this cycle, and begins to lose patience during a government’s term rather than waiting for elections.

When it comes to Pakistan, stories of the military’s growing control may seem to blur into each other. Is anything different this time? Khan was the military’s favored candidate in the 2018 election, and it paved the path to his election. He has gone out of his way to be accommodating to the military, including by extending the current army chief’s tenure. For a time after his election, it seemed that Khan’s closeness with the military might give him the space to implement the domestic policies that he wanted. It seems that period is over. Khan is now clearly constrained by a military whose role has grown progressively through Khan’s term in office and has expanded to the ambit of domestic policy during the pandemic. (Khan’s aides deny this, saying that Khan is still “ calling the shots ,” with the army’s support — a repetition of Khan’s mantra that they are “on the same page.”)

Wither provincial autonomy?

When Khan let the coronavirus response fall to provincial governments this spring, it briefly seemed as if the pandemic might actually help democratic consolidation in Pakistan. Instead, it has opened up a largely unconstructive and inconclusive debate on problems with provincial autonomy and the 18th constitutional amendment that granted it — with those critical of the law pushing back against the initial provincial control of the virus response. Some of the criticisms of the 18th amendment are warranted, but it is no secret that the military doesn’t like the law, which in taking power away from the federal level threatens the military’s power and finances. The provincial autonomy that defined Pakistan’s initial pandemic response is now firmly in the hands of the National Command and Operation Center and the National Coordination Committee.

Illiberalism reigns

The military’s increasing control has also translated to a crackdown on dissent and freedom of the press — a matter on which Khan’s government is studiously quiet. On July 21, a prominent journalist critical of the military and the government, Matiullah Jan, was abducted in Islamabad in broad daylight. He was released that night after an international outcry. In a statement, he said his abduction was the work of forces that are “ against democracy .” And this is not to mention concerns about how intelligence agencies are using militant tracking technologies to trace coronavirus patients and their contacts, and the disturbing potential to use that tracing to crack down further on critical voices.

Pakistan’s provincial governments have also used this time to indulge in illiberal impulses, seemingly taking advantage of a permissive environment to do so. In Punjab, the legislative assembly passed a bill to “protect the foundations of Islam,” by giving the province’s director general of public relations the power to ban any books in the province — published locally or imported — that he or she sees as against the “national interest.” In a similar vein, the head of the Punjab textbook board began banning textbooks chosen by private schools for “anti-Pakistan” or “blasphemous” content — citing objections that the books include Mahatma Gandhi’s quotes or photos of pigs in math equations. Both developments are clearly regressive, a blow to freedoms in Pakistan.

Pakistan’s civilian-military games continue, and democracy loses out

Last week, the state minister for health in Pakistan, a political appointee, resigned , citing political pressure and opposition criticism. Amid the pandemic this summer, Pakistan’s usual civilian-military games continue, with an empowered military and opposition parties all too willing to play the game to help weaken the ruling party. Khan’s political space has now been constricted as much as previous prime ministers, with one difference: He is apparently more willing to cede space to the military for his political preservation. In Pakistan, as in some other countries, the longer-term loser of the pandemic is becoming clear, and it is its democracy.

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• Covid-19: Is a second...

Second wave of Covid-19 in Pakistan; are more episodes down the road?

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Covid-19: Is a second wave hitting Europe?

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Rapid Response:

Dear Editor,

With the unavailability of a specific antiviral or a vaccine, non-pharmaceutical interventions could be the benchmark in curbing SARS-CoV-2 spread and non-compliance to the latter is the obvious cause of a second wave of Covid-19 in Europe [1] and in Pakistan. The government announced a second spell of Covid-19 in Pakistan on October 28, 2020, when a daily increase in cases reached 750 compared to 400 to 500 a few weeks ago. Sudden increase in active cases from 6,000 to 11,000 and hospital admissions with critical cases of 93 on ventilators were recorded across the country [2]. The data released by the National Command and Operation Centre (NCOC) indicate that the current percent positivity rate is closed to 3 compared to the previous figure of less than 2 and the average number of deaths is exceeding 11 per day.

The government is censuring the public for the rise and worsening situation of the pandemic in Pakistan by not observing standard operating procedures (SOPs)--apparently to mask its failure in not taking appropriate steps and decisions which led to the current situation. After the first case of Covid-19 in the last week of February, the infection spread at an alarming speed, albeit the authorities did not address the issue as it should have been done. A meeting of the National Security Committee on March 13 was called on to look into the developing situation after it was declared a pandemic by the World Health Organization. Lockdown like measures were announced later in March but were symbolic as mainly restricted to some major cities, lasted for a period of less than 2 months and were lifted (May 08, 2020) when the damage was the highest for a single day [3].

After the regular activities for a couple of weeks, the ‘smart lockdown’ concept was introduced and hailed by the authorities [4] as an effective tool to curb the virus. In a meeting of the National Coordination Committee (NCC) on August 7, it was announced that COVID-19 pandemic had been controlled due to effective strategy and the country was declared open for routine [5]. The tally went on to 295, 236 mark through September and a new version of the smart lockdown, the 'mini smart lockdown’, was pronounced in some parts of the country [6]. Lack of a stringent policy and lockdown gamble paved the way for SARS-CoV-2 spread through social, political, religious and regular business activities, transport and tourism. Schools, colleges and universities were re-opened for regular activities across the country.

Ultimately, a second wave of the pandemic erupted, according to the authorities. The ground was all set for such a situation in Pakistan [7, 8] but the scary part is that circulation of the SARS-CoV-2 will not stop here and it is highly probable that Covid-19 can become a source of persistent infection if the lesson is not learnt. The first wave claimed 6795 lives, infected 332,186, left behind 632 on ventilators [9] and suffered millions and now we have to watch the second episode, just started in the country.

References 1. Looi MK. Covid-19: Is a second wave hitting Europe? BMJ 2020;371:m4113. doi:10.1136/bmj.m4113 pmid: 33115704 2. Junaidi I. Second Covid wave under way in Pakistan. Dawn. 28 October 2020. https://www.dawn.com/news/1587316 . 3. Abrar M. Pakistan eases lockdown as Covid-19 kills 46 in single-day spike. Pakistan Today. 08 May 2020. https://www.pakistantoday.com.pk/2020/05/07/govt-announces-to-exit-lockd... 4. Pakistan among pioneers of 'smart lockdown' approach, says PM Imran. Dawn. 06 June 2020. https://www.dawn.com/news/1561766 5. COVID lockdown over: Pakistan to open from Monday. The News. 07 August 2020. https://www.thenews.com.pk/print/696942-covid-lockdown-over-pakistan-to-... 6. Sindh govt imposes mini smart lockdown in Karachi as COVID-19 cases spike. The News. 30 September 2020. https://www.thenews.com.pk/latest/722513-sindh-govt-imposes-mini-smart-l... 7. Ali A, Zhongren M, Baloch Z. Covid-19 in Pakistan and potential repercussions for the world: is the infection on the verge of endemicity? BMJ 2020;369:m1909. doi:10.1136/bmj.m1909 pmid: 32409494 8. Ali A, Ma Z, Bai J. Aftermath of torrential rains and covid-19 in Pakistan. BMJ 2020;370:m3776. doi: 10.1136/bmj.m3776 pmid: 32994213 9. Government of Pakistan. Pakistan statistics. http://covid.gov.pk/

Email: [email protected]

Competing interests: No competing interests

Pakistan: Coronavirus Pandemic Country Profile

Research and data: Edouard Mathieu, Hannah Ritchie, Lucas Rodés-Guirao, Cameron Appel, Daniel Gavrilov, Charlie Giattino, Joe Hasell, Bobbie Macdonald, Saloni Dattani, Diana Beltekian, Esteban Ortiz-Ospina, and Max Roser

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• What is the daily number of confirmed cases?
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• Cumulative confirmed cases: how do they compare to other countries?
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Pakistan: What is the daily number of confirmed cases?

Related charts:.

Which world regions have the most daily confirmed cases?

This chart shows the number of confirmed COVID-19 cases per day . This is shown as the seven-day rolling average.

What is important to note about these case figures?

• The reported case figures on a given date do not necessarily show the number of new cases on that day – this is due to delays in reporting.
• The number of confirmed cases is lower than the true number of infections – this is due to limited testing. In a separate post we discuss how models of COVID-19 help us estimate the true number of infections .

→ We provide more detail on these points in our page on Cases of COVID-19 .

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Pakistan: Daily confirmed cases: how do they compare to other countries?

Differences in the population size between different countries are often large. To compare countries, it is insightful to look at the number of confirmed cases per million people – this is what the chart shows.

Keep in mind that in countries that do very little testing the actual number of cases can be much higher than the number of confirmed cases shown here.

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Pakistan: What is the cumulative number of confirmed cases?

Which world regions have the most cumulative confirmed cases?

How do the number of tests compare to the number of confirmed COVID-19 cases?

The previous charts looked at the number of confirmed cases per day – this chart shows the cumulative number of confirmed cases since the beginning of the COVID-19 pandemic.

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We want everyone to build on top of our work and therefore we always make all our data available for download. Click on the ‘Download’-tab at the bottom of the chart to download the shown data for all countries in a .csv file.

Pakistan: Cumulative confirmed cases: how do they compare to other countries?

This chart shows the cumulative number of confirmed cases per million people.

Pakistan: Biweekly cases : where are confirmed cases increasing or falling?

Why is it useful to look at biweekly changes in confirmed cases.

For all global data sources on the pandemic, daily data does not necessarily refer to the number of new confirmed cases on that day – but to the cases  reported  on that day.

Since reporting can vary significantly from day to day – irrespectively of any actual variation of cases – it is helpful to look at a longer time span that is less affected by the daily variation in reporting. This provides a clearer picture of where the pandemic is accelerating, staying the same, or reducing.

The first map here provides figures on the number of confirmed cases in the last two weeks. To enable comparisons across countries it is expressed per million people of the population.

And the second map shows the percentage change (growth rate) over this period: blue are all those countries in which the case count in the last two weeks was lower than in the two weeks before. In red countries the case count has increased.

What is the weekly number of confirmed cases?

What is the weekly change (growth rate) in confirmed cases?

Pakistan: Global cases in comparison: how are cases changing across the world?

In our page on COVID-19 cases , we provide charts and maps on how the number and change in cases compare across the world.

Confirmed deaths

• What is the daily number of confirmed deaths?
• Daily confirmed deaths: how do they compare to other countries?
• What is the cumulative number of confirmed deaths?
• Cumulative confirmed deaths: how do they compare to other countries?
• Biweekly deaths : where are confirmed deaths increasing or falling?
• Global deaths in comparison: how are deaths changing across the world?

Pakistan: What is the daily number of confirmed deaths?

Which world regions have the most daily confirmed deaths?

This chart shows t he number of confirmed COVID-19 deaths per day .

Three points on confirmed death figures to keep in mind

All three points are true for all currently available international data sources on COVID-19 deaths:

• The actual death toll from COVID-19 is likely to be higher than the number of confirmed deaths – this is due to limited testing and challenges in the attribution of the cause of death. The difference between confirmed deaths and actual deaths varies by country.
• How COVID-19 deaths are determined and recorded may differ between countries.
• The death figures on a given date do not necessarily show the number of new deaths on that day, but the deaths  reported  on that day. Since reporting can vary significantly from day to day – irrespectively of any actual variation of deaths – it is helpful to view the seven-day rolling average of the daily figures as we do in the chart here.

→ We provide more detail on these three points in our page on Deaths from COVID-19 .

Pakistan: Daily confirmed deaths: how do they compare to other countries?

This chart shows the daily confirmed deaths per million people of a country’s population.

Why adjust for the size of the population?

Differences in the population size between countries are often large, and the COVID-19 death count in more populous countries tends to be higher . Because of this it can be insightful to know how the number of confirmed deaths in a country compares to the number of people who live there, especially when comparing across countries.

For instance, if 1,000 people died in Iceland, out of a population of about 340,000, that would have a far bigger impact than the same number dying in the United States, with its population of 331 million. 1 This difference in impact is clear when comparing deaths per million people of each country’s population – in this example it would be roughly 3 deaths/million people in the US compared to a staggering 2,941 deaths/million people in Iceland.

Pakistan: What is the cumulative number of confirmed deaths?

Which world regions have the most cumulative confirmed deaths?

The previous charts looked at the number of confirmed deaths per day – this chart shows the cumulative number of confirmed deaths since the beginning of the COVID-19 pandemic.

Pakistan: Cumulative confirmed deaths: how do they compare to other countries?

This chart shows the cumulative number of confirmed deaths per million people.

Pakistan: Biweekly deaths : where are confirmed deaths increasing or falling?

Why is it useful to look at biweekly changes in deaths.

For all global data sources on the pandemic, daily data does not necessarily refer to deaths on that day – but to the deaths  reported  on that day.

Since reporting can vary significantly from day to day – irrespectively of any actual variation of deaths – it is helpful to look at a longer time span that is less affected by the daily variation in reporting. This provides a clearer picture of where the pandemic is accelerating, staying the same, or reducing.

The first map here provides figures on the number of confirmed deaths in the last two weeks. To enable comparisons across countries it is expressed per million people of the population.

And the second map shows the percentage change (growth rate) over this period: blue are all those countries in which the death count in the last two weeks was lower than in the two weeks before. In red countries the death count has increased.

What is the weekly number of confirmed deaths?

What is the weekly change (growth rate) in confirmed deaths?

Pakistan: Global deaths in comparison: how are deaths changing across the world?

In our page on COVID-19 deaths , we provide charts and maps on how the number and change in deaths compare across the world.

• How many COVID-19 vaccine doses are administered daily ?
• How many COVID-19 vaccine doses have been administered in total ?
• What share of the population has received  at least one dose  of the COVID-19 vaccine?
• What share of the population has  completed the initial vaccination protocol ?
• Global vaccinations in comparison: which countries are vaccinating most rapidly?

Pakistan: How many COVID-19 vaccine doses are administered daily ?

How many vaccine doses are administered each day (not population adjusted)?

This chart shows the daily number of COVID-19 vaccine doses administered per 100 people in a given population . This is shown as the rolling seven-day average. Note that this is counted as a single dose, and may not equal the total number of people vaccinated, depending on the specific dose regime (e.g., people receive multiple doses).

Pakistan: How many COVID-19 vaccine doses have been administered in total ?

How many vaccine doses have been administered in total (not population adjusted)?

This chart shows the total number of COVID-19 vaccine doses administered per 100 people within a given population. Note that this is counted as a single dose, and may not equal the total number of people vaccinated, depending on the specific dose regime as several available COVID vaccines require multiple doses.

Pakistan: What share of the population has received  at least one dose  of the COVID-19 vaccine?

How many people have received at least one vaccine dose?

This chart shows the share of the total population that has received at least one dose of the COVID-19 vaccine. This may not equal the share with a complete initial protocol if the vaccine requires two doses. If a person receives the first dose of a 2-dose vaccine, this metric goes up by 1. If they receive the second dose, the metric stays the same.

Pakistan: What share of the population has  completed the initial vaccination protocol ?

How many people have completed the initial vaccination protocol?

The following chart shows the share of the total population that has completed the initial vaccination protocol. If a person receives the first dose of a 2-dose vaccine, this metric stays the same. If they receive the second dose, the metric goes up by 1.

This data is only available for countries which report the breakdown of doses administered by first and second doses.

Pakistan: Global vaccinations in comparison: which countries are vaccinating most rapidly?

In our page on COVID-19 vaccinations, we provide maps and charts on how the number of people vaccinated compares across the world.

Testing for COVID-19

• The positive rate
• The scale of testing compared to the scale of the outbreak
• How many tests are performed each day ?
• Global testing in comparison: how is testing changing across the world?

Pakistan: The positive rate

Here we show the share of reported tests returning a positive result – known as the positive rate.

The positive rate can be a good metric for how adequately countries are testing because it can indicate the level of testing relative to the size of the outbreak. To be able to properly monitor and control the spread of the virus, countries with more widespread outbreaks need to do more testing.

It can also be helpful to think of the positive rate the other way around:

How many tests have countries done for each confirmed case in total across the outbreak?

Pakistan: The scale of testing compared to the scale of the outbreak

How do daily tests and daily new confirmed cases compare when not adjusted for population ?

This scatter chart provides another way of seeing the extent of testing relative to the scale of the outbreak in different countries.

The chart shows the daily number of tests (vertical axis) against the daily number of new confirmed cases (horizontal axis), both per million people.

Pakistan: How many tests are performed each day ?

This chart shows the number of  daily  tests per thousand people. Because the number of tests is often volatile from day to day, we show the figures as a seven-day rolling average.

What is counted as a test?

The number of tests does not refer to the same thing in each country – one difference is that some countries report the number of people tested, while others report the number of tests (which can be higher if the same person is tested more than once). And other countries report their testing data in a way that leaves it unclear what the test count refers to exactly.

We indicate the differences in the chart and explain them in detail in our accompanying  source descriptions .

Pakistan: Global testing in comparison: how is testing changing across the world?

In our page on COVID-19 testing , we provide charts and maps on how the number and change in tests compare across the world.

Case fatality rate

• What does the data on deaths and cases tell us about the mortality risk of COVID-19?
• The case fatality rate
• Learn in more detail about the mortality risk of COVID-19

Pakistan: What does the data on deaths and cases tell us about the mortality risk of COVID-19?

To understand the risks and respond appropriately we would also want to know the mortality risk of COVID-19 – the likelihood that someone who is infected with the disease will die from it.

We look into this question in more detail on our page about the mortality risk of COVID-19 , where we explain that this requires us to know – or estimate – the number of total cases and the final number of deaths for a given infected population.

Because these are not known , we discuss what the current data on confirmed deaths and cases can and can not tell us about the risk of death. This chart shows both those metrics.

Pakistan: The case fatality rate

Related chart:.

How do the cumulative number of confirmed deaths and cases compare?

The case fatality rate is simply the ratio of the two metrics shown in the chart above.

The case fatality rate is the number of confirmed deaths divided by the number of confirmed cases.

This chart here plots the CFR calculated in just that way. 

During an outbreak – and especially when the total number of cases is not known – one has to be very careful in interpreting the CFR . We wrote a  detailed explainer  on what can and can not be said based on current CFR figures.

Pakistan: Learn in more detail about the mortality risk of COVID-19

Learn what we know about the mortality risk of COVID-19 and explore the data used to calculate it.

Government Responses

• Government Stringency Index

To understand how governments have responded to the pandemic, we rely on data from the Oxford Coronavirus Government Response Tracker  (OxCGRT), which is published and managed by researchers at the Blavatnik School of Government at the University of Oxford.

This tracker collects publicly available information on 17 indicators of government responses, spanning containment and closure policies (such as school closures and restrictions in movement); economic policies; and health system policies (such as testing regimes).

How have countries responded to the pandemic?

Travel bans, stay-at-home restrictions, school closures – how have countries responded to the pandemic? Explore the data on all policy measures.

Pakistan: Government Stringency Index

The chart here shows how governmental response has changed over time. It shows the Government Stringency Index – a composite measure of the strictness of policy responses.

The index on any given day is calculated as the mean score of nine policy measures, each taking a value between 0 and 100. See the authors’  full description  of how this index is calculated.

A higher score indicates a stricter government response (i.e. 100 = strictest response).

The OxCGRT project calculates this index using nine specific measures, including:

• school and workplace closures;
• restrictions on public gatherings;
• transport restrictions;
• and stay-at-home requirements.

You can see all of these separately on our page on policy responses . There you can also compare these responses in countries across the world.

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United States Institute of Peace

Home ▶ Events

Pakistan’s Post-Pandemic Economic Outlook

Date:  Tuesday, April 6, 2021  /   Time:  9:00am - 10:30am EDT

Center: Asia Center

The COVID-19 pandemic has been a blow to Pakistan’s economy, which had already slowed down considerably after experiencing a twin-deficit crisis in 2018. The impact of the pandemic prompted Prime Minister Imran Khan’s government to roll out a massive stimulus, seek international debt relief, and suspend the IMF program. In the last few weeks, the economy has started to recover, and the country is set to restart the suspended IMF program in the coming days. Additionally, with the new Biden administration, Pakistan is seeking to redefine its bilateral relationship with the United States on geoeconomics terms, as it attempts to shrug off the pandemic’s debilitating economic effects.

On April 6, USIP hosted a discussion that assessed the economic impact of the COVID-19 pandemic on the Pakistani economy, explored the outlook for reforms, and surveyed how international investors, especially U.S. companies, view the Pakistani economy and investment prospects.

Continue the conversation on Twitter with  #EconOutlookPK .

Khurram Husain Economic writer, Dawn

Safiya Ghori-Ahmed Director, McLarty Associates

Naila Naqvi CEO, Pie in the Sky

Uzair Younus , moderator Visiting Senior Policy Analyst, South Asia Program, U.S. Institute of Peace

Related Publications

Toward a Durable India-Pakistan Peace: A Roadmap through Trade

Thursday, June 27, 2024

By: Sanjay Kathuria

Despite a three-year long cease-fire along their contested border, trade and civil society engagement between India and Pakistan has dwindled, exacerbating the fragility of their relationship. With recently re-elected governments now in place in both countries, there is a window of opportunity to rekindle trade to bolster their fragile peace, support economic stability in Pakistan, create large markets and high-quality jobs on both sides, and open doors for diplomatic engagement that could eventually lead to progress on more contentious issues.

Type: Analysis

How Have India’s Neighbors Reacted to Its Election?

Tuesday, June 25, 2024

By: Humayun Kabir;   Geoffrey Macdonald, Ph.D. ;   Nilanthi Samaranayake ;   Asfandyar Mir, Ph.D.

Narendra Modi was sworn in on June 9 for his third consecutive term as India’s prime minister. Public polls had predicted a sweeping majority for Modi, so it came as some surprise that his Bharatiya Janata Party (BJP) lost ground with voters and had to rely on coalition partners to form a ruling government. Although India’s elections were fought mainly on domestic policy issues, there were important exceptions and Modi’s electoral setback could have implications for India’s regional and global policies.

Global Elections & Conflict ;  Global Policy

What Does Further Expansion Mean for the Shanghai Cooperation Organization?

Thursday, May 30, 2024

By: Bates Gill;   Carla Freeman, Ph.D.

Last week, foreign ministers from member-states of the Shanghai Cooperation Organization (SCO) gathered in Astana, Kazakhstan. The nine-member SCO — made up of China, India, Russia, Pakistan, Iran, Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan — represents one of the largest regional organizations in the world. And with the SCO’s annual heads-of-state summit slated for early July, the ministers’ meeting offers an important glimpse into the group’s priorities going forward. USIP’s Bates Gill and Carla Freeman examine how regional security made its way to the top of the agenda, China’s evolving role in Central Asia and why SCO expansion has led to frustrations among member states.

Type: Question and Answer

Global Policy

Asfandyar Mir on Balancing Counterterrorism and Strategic Competition

Tuesday, May 21, 2024

By: Asfandyar Mir, Ph.D.

As terror threats emanating from Afghanistan and Pakistan rise, many may see counterterrorism as a distraction from other U.S. priorities, such as competition with China and Russia. But investment in counterterrorism can work “preventively, to shield the strategic competition agenda,” says USIP’s Asfandyar Mir.

Type: Podcast

Course is available

سانس کے نئے وائرس، جن میں کووڈ-19 بھی شامل ہے: ان کو بھانپنے، روکنے، مقابلے اور قابو پانے کے طریقے

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کورونہ وائرس ایک بہت بڑی وائرس کی فیملی کا نام ہے جو ایک بیماری پیدا کرتے ہیں جی میں عمومی بخار سے لے کر سخت بیماریاں جیسا کہ وسطی ایشیا کی سانس کی وبا (MERS) اور پچیدہ جان لیوہ سانس کی وبا (SARS) شامل ہیں۔

نوول کورونہ وائرس (COVID-19) چائنہ کے شہر ووہان میں 2019 میں ملا تھا۔ یہ ایک نیا کورونہ وائرس ہے جو اس سے پہلے انسانوں میں نہیں دیکھا گیا۔

یہ کورس COVID-19 اور دوسرے بڑھتے ہو وائرسوں کے لیے کے متعلق عمومی تعارف بیان کرتا ہے ان افراد کو جو عوامی صحت کے پیشہ ور، موقعے پر موجود افراد اور جو لوگ یونائیٹڈ نیشنز، بین الاقوامی اداروں اور این جی اوز کے لیے کام کرتے

براہ کرم نوٹ کریں کہ اس کورس کے مواد میں حالیہ رہنمائی کی عکاسی کرنے کے لیے فی الحال نظر ثانی کی جا رہی ہے۔ آپ درج ذیل کورسز میں COVID-19 سے متعلقہ بعض موضوعات پر تازہ ترین معلومات حاصل کر سکتے ہیں: ویکسینیشن: COVID-19 ویکسینز چینل اقدامات انفیکشن کی روک تھام اور کنٹرول: IPC برائے COVID-19 اینٹیجن ریپڈ ڈائیگنوسٹک ٹیسٹنگ: 1) SARS-CoV-2 اینٹیجن ریپڈ ڈائیگنوسٹک ٹیسٹنگ ؛ 2) SARS-CoV-2 اینٹیجن RDT کے نفاذ کے لیے اہم تحفظات

براہ کرم نوٹ کریں: یہ مواد آخری بار 16/12/2020 کو اپ ڈیٹ کیا گیا تھا۔

Course contents

ماڈیول الف: ابھرتے ہوئے سانس کے وائرس کا تعارف ، بشمول covid-19:, ماڈیول ب : covid-19 سمیت سانس کے ابھرتے ہوئے وائرس کا پتہ لگانا: نگرانی اور لیبارٹری میں تحقیقات :, ماڈیول ج: خطرے کی اطلاعات اور کمیونٹی کی مصروفیت:, ماڈیول د: ایک ابھرتی ہوئی سانس کے وائرس کی روک تھام اور اس کا جواب ، جس میں کووڈ 19 بھی شامل ہے:, enroll me for this course, certificate requirements.

• Gain a Record of Achievement by earning at least 80% of the maximum number of points from all graded assignments.
• Gain an Open Badge by completing the course.