Until a vaccine becomes available, compliance by organisations and citizens is the way forward.
Given the scale of Covid-19 and the degree of uncertainty around it, public attention in Pakistan has rightly focused on how to come up with an effective policy response at the national and provincial levels. However, formulating an optimal policy is only part of the challenge; properly implementing it and making corrections as we go along is as important. Effective implementation cannot be achieved through a centralised and top-down approach by the government as it requires actions and cooperation of many groups — enforcement by agents of the state, appropriately empowered local decision-making structures exercising legitimacy, and voluntary compliance by both organisations and citizens.
It is often lamented that rules and Standard Operating Procedures (SOPs) in Pakistan rarely make it past the paper they are written on. In a recent Human Rights Commission Pakistan study of 415 people across 70 districts, over 75 per cent of respondents were not satisfied with the government’s response to Covid-19. When asked why, the most common reason given was that government SOPs were not being enforced (62 per cent of the respondents stated this). Pakistan’s long-standing weakness in implementing policies and SOPs is now proving to be very costly. In the face of Covid-19, our inability to implement proven measures that are critical in protecting the economy and public health is affecting us all adversely.
Let’s start by considering two examples of critical Covid-19 containment measures that we have not yet been able to implement effectively despite creating SOPs.
First, the close regulation of large religious gatherings in crowded spaces is essential because congregating in close proximity during prayers and sermons is known to increase the chance of one infected person spreading the virus to several others in a short period. The Tabhleegi Jamaat congregation at Raiwind, with over 250,000 people in participation, is a clear example of a super-spreader event where a handful of Covid-19 positive individuals likely infected thousands of others. Although, a 20-point SOP for the operation of mosques was issued by the federal government on April 19, just a few days later reports and photographic evidence showed gatherings of hundreds of people standing shoulder to shoulder — in clear violation of the standard operating procedures — across the country, including in the federal capital. This example highlights implementation failure at two levels, where citizens do not adhere to SOPs and where the state lacks the capacity to enforce them.
The second critical containment measure is the prevention of infection spread in workplaces. The most basic and essential protective measure for workplaces is that people with symptoms of Covid-19 do not come to work for at least seven days to avoid infecting other workers. The infection can spread easily in workplaces, as seen when 94 out of 216 employees in a call center in South Korea tested positive. Other important workplace measures include ensuring physical distancing protocols are followed, encouraging behaviour change, such as wearing masks and not shaking hands, adopting the ROTA1 system where only certain teams come into the office at one time and encouraging remote work where possible, among many others.
Following recommendations by the National Coordination Committee on Covid-19, detailed organisational SOPs tailored to various industries were issued on April 14 by provincial governments. However, there was a lack of engagement and coordination with business owners to ensure voluntary compliance to measures that could reduce profitability. There was more emphasis on cleaning and disinfection of premises, without due attention to whether employers would be able to provide paid sick leave to infected workers who need to stay home for several days when sick. As places of work begin opening up, there is an urgent need to work out a financial protection mechanism for workers and encourage voluntary compliance of SOPs by business owners.
Moving from the past to the present, with Eidul Azha around the corner, the prime minister himself has stepped in to remind the public through a Twitter message that they 'should not repeat what happened last Eid when SOPs were ignored and our hospitals were choked'. Based on the data collected by the government, there was a large increase in daily Covid-19 cases across Pakistan within two weeks (typical time period from infection to symptoms) of Eidul Fitr, which fell on May 24. This trend shows a strong link between non-compliance of SOPs during Eid and the surge in Covid-19 cases.
The prime minister's Twitter message goes on to 'order strict implementation of government SOPs', but are these orders really going to work?
We already know about the main barriers to implementing policies in Pakistan and around the world, and this gives us the opportunity to overcome them. First, we must realise that apart from the government’s responsibility, non-state agencies (including firms, professional associations, community groups) and citizens also have a role to play in supporting implementation. Supporting the government in implementing SOPs is especially important in a crisis situation such as the one we find ourselves in. Second, it is important to consider that apart from enforcement of government rules through penalties for non-compliance, implementation of SOPs can also occur through voluntary compliance by organisations and citizens.
Voluntary compliance can work well in countries such as Pakistan where systems and resources for monitoring and for enforcing penalties by government agencies are weak. But there is a lot of work that needs to be done to convince non-state organisations and individuals to comply with SOPs voluntarily. According to a Gallup poll conducted in March 2020, 43 per cent Pakistanis had not taken any precautionary measures to protect themselves from coronavirus — the highest percentage of citizens from the 28 nations polled.
In order to positively influence behaviours of Pakistani citizens, community groups and organisations, there are three essential pillars that must be put in place.
The first is clear and effective communication about what needs to be done, why it needs to be done and who is responsible. By clearly communicating these expectations and identifying those responsible, there is a clear line of action that encourages active behaviour. Channels of communication used should be appropriate to reach the desired audience and can include telephone hotlines, websites, mass media and social media.
Transparency is the second essential pillar, as this leads to trust. One of the greatest challenges in promoting voluntary compliance in Pakistan has been the trust deficit between the government and the citizens, which has long existed. While there is no band-aid solution to quickly fix this trust deficit overnight, becoming more transparent in its dealings may help government officials build confidence among citizens. Some proven strategies that promote transparency are highlighting the risks, costs and benefits associated with various policy responses; fiscal transparency of policy responses; and public accountability. These will help restore public trust and build legitimacy. One great example of building trust and protecting vulnerable communities has been through the largest poverty relief package announced by the federal government with a value of PKR 1.25 trillion, out of which PKR 200 million was provided to daily wage labourers and PKR 144 million was disbursed as unconditional cash assistance. However, much more transparency is needed for the federal and provincial governments to enable greater voluntary compliance. Empowering local actors, including elected local governments, is another way of leveraging local information and networks and bringing accountability closer to citizens.
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Third, understanding the incentives for implementing changes in the way individuals or organisations operate is also essential, so that key stakeholders for implementation are motivated to comply. For example, many members of the public are reluctant to get tested even when they experience severe symptoms because of the fear of being forcefully quarantined in inadequate government facilities. In this case, there is a disincentive to coming forward for testing and a perception of unequal treatment as the elite are seemingly easily able to evade rules on quarantine. In order to build trust and ensure compliance, the government thus needs to adopt and communicate sensible policies but also have compassionate and just enforcement mechanisms.
Since Pakistan has moved out of the first phase of containment based mainly on state enforced lockdowns, we can enjoy more freedom, but we must accept that this freedom comes with more responsibility to cooperate and comply with protocols put in place for our safety. By taking small precautions and adopting compliance behaviours, we can collectively slow the spread of the virus and potentially also save lives. Until a vaccine becomes available, compliance by organisations and citizens is the way forward.
The Analytical Angle is a monthly column where top researchers bring rigorous evidence to policy debates in Pakistan. The series is a collaboration between the Centre for Economic Research in Pakistan and Dawn.com. The views expressed are the authors’ alone.
Mishal Khan MA (Cantab), PhD is an Associate Professor of Health Policy and Systems at the London School of Hygiene and Tropical Medicine, a Consultant at the Centre for Universal Health at Chatham House (UK) and a visiting faculty member of the Aga Khan University. She tweets @DrMishalK
Maheen Rashid is a Policy Associate on the Policy Advisory team at the Centre for Economic Research in Pakistan (CERP) and works on bridging the gap between academic research and policy implementation. Maheen holds a Master of Public Policy degree from Rutgers University and a Bachelor’s degree in Accounting and Finance from the Lahore University of Management Sciences (LUMS). She tweets at @MinoRashid
Adnan Qadir Khan is a professor in practice, School of Public Policy and STICERD, London School of Economics. He is a co-founder of the Centre for Economic Research in Pakistan and has served as research and policy director at the International Growth Centre. He tweets at @adnanqk
The views expressed by this writer and commenters below do not necessarily reflect the views and policies of the Dawn Media Group.