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Decision-making during a pandemic

It’s between reality and fiction, between half hope and half fear. The National Action Plan to contain Covid-19 through short and long-term measures is there, but its full implementation requires the full push by the top political and constitutional institutions.

In the face of confusion over how policies are made and implemented till the union council level, the official decision-making can be coded as a classic example of the famous ‘Garbage Can Theory’, in which problems, solutions, participants and choice opportunities flow in and out of a garbage can. Problems that get attached to solutions are mostly due to chance.

The ‘Garbage Can Model’ or garbage can process was developed in a seminal paper written around four decades ago by Michael D Cohen, James G March, and Johan P. Olsen It describes the chaotic reality of organizational decision-making in an organized anarchy.

No doubt, Pakistan’s healthcare system is in shambles. Still, while Covid-19 posed challenges to the global health security environment under International Health Regulations (IHR), One Health Approach, and the Global Health Security Agenda (GHSA), it is further defining the fragility of Pakistan’s healthcare security.

However, putting different agenda settings at a national, international, and provincial level along with different solutions and processes in the garbage can have created hope for the reincarnation of the national healthcare system of Pakistan.

One of the critical binding documents is the International Health Regulations (IHR) 2005., where recently Pakistan scored at 2. In the strategic preparedness and response plan by the WHO Eastern Mediterranean Region in February 2020, the maximum score for each of the technical areas is 5 (sustainable capacity), and the minimum score is 1 (no capacity). Scores 2, 3, and 4 correspond to limited, developed, and demonstrated capacity, respectively.

The areas that were used to measure capacity of a country relevant to Covid-19 included IHR coordination; infection prevention and control; laboratory and biosecurity/biosafety; surveillance; reporting; preparedness; emergency response; risk communications; and points of entry.

No wonder, Pakistan faced two-pronged issues of fighting Covid-19 and simultaneously establishing the required health security infrastructure like quarantine facilities, imported and locally produced standardized ventilators, hand sanitizers, Personal Protection Equipment and secure quality testing kits and enhancing the laboratory capacity.

This process was initiated by invoking a mix of institutions and regulations, including that of the National Institute of Health, Drug Regulatory Authority, Pakistan Engineering Council, National Disaster Management Authority, and the Defense Science and Technology Organization (DESTO). Now, these makeshift processes need to be consolidated.

IRS 2005 reflects the WHO’s responsibility for the management of the global regime for the control of the international spread of disease by adopting regulations “designed to prevent the international spread of disease.” These, after adoption by the Health Assembly, enter into force for all WHO member states. These regulations are binding on Pakistan.

The purpose and scope of the IHR (2005) are “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.”

The IHR covers “illness or medical condition, irrespective of origin or source, that presents or could present significant harm to humans.”

The government is also under obligation to develop specific minimum core public health capacities. It also authorizes the WHO to take into consideration unofficial reports of public health events and to obtain verification from States Parties concerning such events and procedures for the determination by the director-general of the WHO of a “public health emergency of international concern” and issuance of corresponding temporary recommendations.

Another WHO approach is ‘One Health’, which is to design and implement programmes, policies, legislation and research in which multiple sectors communicate and work together to achieve better public health outcomes.

Connected to this is the Global Health Security Agenda (GHSA) that was launched in 2014. Its vision is of attaining a world safe and secure from global health threats posed by infectious diseases. The GHSA includes sharing best practices, elevating global health security as a national leaders’ level priority, and facilitating national capacity to comply with and adhere to the IHR, the World Organization for Animal Health (OIE) international standards and guidelines, the United Nations Security Council Resolution 1540 and Biological Weapons Convention, and other relevant frameworks that contribute to global health security.

Taking a cue from these international health security frameworks, Pakistan’s Ministry of National Health Services, Regulations and Coordination evolved a National Action Plan on Covid-19. The NAP, in the short term, calls for the mobilization of available financial resources for effective preparedness and efficient response by ensuring that all safeguards are in place to prevent outbreak.

In the medium term, it talks of strengthening and reforms of the organizational, structural, and coordination mechanisms to ensure a maximum level of preparedness and robust surveillance and response structures throughout Pakistan, ensuring compliance with international health regulations. In the longer run, it will contribute to the development of a robust national health security agenda for all hazards and a pandemic preparedness framework for Pakistan.

The NAP also provides healthcare providers with SOPs on how to manage Covid-19 cases as well as standards for hand sanitizers, ventilators, personal protection equipment, etc.

To support this, the Asian Development Bank (ADB) has repurposed $50 million from Pakistan’s National Disaster Risk Management Fund (NDRMF) to support the country’s preventive and response efforts to fight the novel coronavirus disease. The funds will help procure medical equipment and supplies to strengthen hospitals, diagnostic laboratories, isolation units, and other medical facilities in the country.

The NDRMF is a government-owned not-for-profit institution registered with the Securities & Exchange Commission of Pakistan under Section 42. The fund’s board of directors has dominant federal and provincial governments’ presence. The fund also supports the National Disaster Management Authority.

In pursuit of the global health security agenda, three years ago in 2017 Pakistan formulated the National Laboratory Policy, and the National Laboratory, Biosafety and Biosecurity Policy. The laboratory policy recognized that poor laboratory services are costly in terms of high wastage of scarce public resources and private out-of-pocket expenditures on ineffective treatments, loss of economic productivity of the population due to (chronic) illness, and loss of life of humans and animals alike. Therefore, the policy aimed at developing an infrastructure that can give accurate and reliable diagnosis for disease management and prevention.

The biosafety policy, on the other hand, aimed more at the infectious disease panorama, which is changing with emerging and re-emerging infectious agents. And as the laboratories handle potentially hazardous biological materials, therefore a dire need for guidance is essential to ensure safe and secure operations.

Unfortunately, the action that should have come out from these policies remained confined to them, and the country has had to face the coronavirus pandemic virtually with bare hands.

In Pakistan, it is clear that policymaking is an executive function, but if policy approval is an intra or inter-ministerial work or the domain of the cabinet or parliament it is yet to be lineated. No doubt, in post-devolution constitutional health security arrangements, all health policies must have joint federal and provincial political ownership.

The Council of Common Interests provides that needed framework to realize the effect of these policies all through to the district level.

Nadeem Iqbal, "Decision-making during a pandemic," The News. 2020-04-20.
Keywords: Health sciences , Political ownership , Health policies , Economic productivity , Medical Facilities , National health , Health services , Healthcare system , Decision making , Covid-19