Withstanding health shocks

March 28, 2020

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The writer is a graduate of Harvard University in health policy and management.
The writer is a graduate of Harvard University in health policy and management.

NEVER has the slogan of global health security resounded so loudly as now. Dubbed earlier by sceptics as the West’s right-centre agenda to keep migration and poverty out under the banner of disease, it has come to haunt all states as they struggle with the Covid-19 pandemic. So, what is global health security? It is about minimising the collective damage from public health events that can endanger lives across borders, if not contained, as they are a threat to economic prosperity and national security. The mantra is simple: prevent, detect, respond, mitigate; the response is unique as it relies on a whole-of-government approach.

Pakistan’s score on the Global Health Security Index overall is 35 out of 100 and it ranks 105 out of 195 nations. Before the critics descend, no, Pakistan is not in the ranking of ‘least prepared’ countries, but in that of ‘more prepared countries’. The average score is only 52 for high-income countries. No country, even with the best health system, is fully prepared for the sudden onslaught of Covid-19, but preparedness can determine how quickly a country can bounce back to respond, mitigate and recover — ie how resilient it is.

Pakistan does not have a coordinated and publicised national public health emergency plan.

Pakistan’s country score is propped up by its score on laboratory capability and skilled professionals. The least scores, close to zero, are for cross-border agreements, emergency planning, ability to track infections, communication with health workers during medical emergencies, infection control practices in health centres, and health system capacity.

The quarantine faux pas at the Taftan border has shown the fragility of the federal-provincial combined planning for emergencies and cross-border situations. Several hundred suspected patients kept in crowded, unhygienic conditions bred and transmitted the virus in multiplying loads. Quarantine requires science but also considerable resources.

While contingency plans devised by the national and provincial disaster management agencies for natural calamities exist, the country does not have a coordinated and publicised national public health emergency plan or dedicated funding lines in the federal and provincial budgets for health emergencies. In the 10 years since devolution, it is still unclear as to who will lead and fund health emergency preparedness, with the provinces left to their own devices and relying on their own pockets and the interest of their chief ministers. Flexible contingent financing for health ministries for emergency situations through domestic budgets, as well as global risk financing, is critical to allow a quick response to disease outbreaks, whether it is Covid-19, dengue or drug-resistant typhoid.

To its credit, Pakistan has produced a number of epidemiologists trained to track and investigate infections, but none are found leading the charge at health ministries to guide the response of health taskforces. More is being heard from the showbiz side than the scientists.

With the virus seeded in all provinces, the existing policy of track, contain and confine at home is the best hope. The health response has to be inverted, with downstream action, discouraging a rush to clinics and hospitals to keep people away from infecting healthcare centres or getting infected, unless they actually require hospitalisation. And for this we must harness our overlooked potential for digital connectivity and communication.

According to the PTA, there are 161.8 million mobile users in Pakistan and 68m users of 3G-4G internet bundles. The current pandemic is galvanising innovations globally — some countries are using digitech for active surveillance, contact tracking and GIS mapping, yet others for SMS check-in by self-quarantined persons. Mobile platforms are connecting several thousand doctors and health workers for point-of-contact guidelines, referrals and dashboards, and still others for teleconsultations supported by remote vital monitoring platforms to measure temperature, oxygen levels and the vitals of patients remotely. The present crisis is a test of fast-track reliance on digitech healthcare in Pakistan. It is also time for the world to set aside copyrights on digital innovations and share solutions for the global good.

Now for the question of the capacity of emergency health services. The country’s existing healthcare system will likely face a double burden, coping with Covid-19 as well as catering for acute events such as injuries from road accidents and ongoing care for the chronically ill. Many of Pakistan’s doctors trained through public-sector funding are not in active service. Nurses, paramedics and laboratory technicians who form the backbone of intensive care and diagnostic services in hospitals are in even shorter supply. Mobilising health workers, training and providing them with protective gear, along with priority testing for workers who show symptoms, are critical action points. It is important to continue to fill in for health workers who fall sick and have to isolate themselves.

Boosting health services will of course require recourse to our favourite policy buzzword — public-private partnerships. Setting aside the IMF bind, local industry must be incentivised for production of essential medical equipment, supplies, protective gear and simple hand-washes. Private and parastatal hospitals must collectively rise to a call to action by postponing non-urgent procedures to free up beds in readiness for Covid-19 cases, ramp up laboratory testing, and assist in setting up makeshift hospitals and modular safe testing centres.

Even with full mobilisation of the public-private health system, if the virus peaks, doctors may need to make hard choices about whom to prioritise care for — the elderly and those with underlying illness, or the young and healthy. What must not happen is the prioritisation of the more influential versus those with less influence in Pakistan’s ingrained power and patronage system.

While new tallies of Covid-19 cases will be headlined daily over the next few weeks, what has not been mathematically modelled is the economic and social cost. As a famous ex-prime minister of the UK said, “the more you intervene to deal with the medical emergency, the more you put economies at risk”. High-income countries can take the burden of enforcing social distancing for several weeks while straining their benefit structures; for countries such as Pakistan, the timing of social distancing has to be early as it cannot be enforced for long. It will be a knife-edge act for policymakers balancing between avoiding deaths at one end and poverty and recession on the other.

The writer is a graduate of Harvard University in health policy and management.

Published in Dawn, March 28th, 2020