AURORA: What is the basis for the government’s assertion that it has handled the pandemic well?

FAISAL SULTAN: We can talk about numbers and other things, but the most obvious objective when the pandemic began was to ensure that the health system was not overwhelmed. There were two peaks and in both cases, we were able to avoid running out of hospital beds or allowing the health system to trip. At all stages, we had the capacity – this is one way of looking at it. If we look at it from the point of view of mortality per capita, it has been lower than in many regions. In fact, the entire region has done better compared to European countries.

A: There has been criticism that the testing has been low and that the numbers are deceptive.

FS: No one can test an entire population apart from small island nations. All other countries depend on samples. Leave aside testing – anyone who becomes unwell with any illness with a respiratory component cannot ignore it. When you are very unwell, you are going to reach for the health system. Hence, we measure the capacity of the health system rather accurately, especially as there are a finite number of health institutions. Then there is the number of deaths. We have a fairly robust system of ascertaining this – it is never 100%, but the data is clear. When the number of tests began to go up, the positivity rate went up, hospitals filled up, patients on ventilators went up, oxygen consumption went up and we had data on this as well. When the numbers began to decline, all these indicators went down. Even the numbers given by oxygen vendors followed this pattern. All the numbers synced with each other even though they were coming from different sources – the tests came from laboratories, admission numbers from hospitals and so on. There is no question that there were two peaks; the first peak was higher but the second was longer and once the number of deaths was calculated on a per capita basis, they were better than many other countries.

A: Was the government’s strategy to ‘manage’ the pandemic while keeping the economy going or was ‘elimination’ a strategy in the earlier days?

FS: Once the virus was out of Wuhan, elimination was not an option. The people who spoke about elimination did not know enough. Many of us are not scientifically literate. When people were pushing for a lockdown, many were saying that the numbers were not high enough.

A: Yet the government implemented it. 

FS: Initially, there was a perception in one province that we needed to do it and then the others latched on to the idea. It was a reasonable reaction. When something happens in real-time, you do not have all the facts. In the beginning, it is okay to carry out a harsher blanket intervention and then catch your breath. It’s akin to waking up in the middle of the night and wondering if the noise is a cat outside or an intruder. So, it is fine to shut all the doors quickly. Similarly, the lockdown was premature but procedurally it was the right thing to do. Once the numbers were collected, it was decided that we could extricate ourselves. However, there was a post-Eid surge, which led to the first peak. Paradoxically, the first lockdown happened before the peak.

A: In hindsight, what do you think worked?

FS: The coordination between the provinces was very important. A coherent response is a major challenge in large countries. Wherever there are federal devolved structures and the response is not coherent, there are problems. (For example, mandates vary from state to state, there are different testing algorithms or restrictions, such as restaurants being open in one place and not in another, or mask use changing within state borders.) In Pakistan, we were able to get under one roof with the National Command Operation Centre (NCOC) and talk to one another and build a fair amount of consensus. We also took two important decisions at the beginning that had a huge impact. We closed educational institutes and marriage halls and did not reopen either until September. This effectively stopped large massive gatherings for a long period. Then came the lockdown, which also served a purpose. Contact tracing was also an important step – we are tracing up to 10 contacts, which is no mean achievement in a country like Pakistan. In the beginning, we had one lab, then four, and our capacity now is about 50,000 to 60,000 tests a day. The next big step was to gain the confidence of the health workforce by providing them with PPE. There was a serious shortage but the National Disaster Management Authority (NDMA) stepped in and purchased them and now we have indigenised them. Don’t forget the Ehsaas Programme, which helped the people most affected by the lockdown. However, some external factors may have helped us. Diseases work in a triad – the host, the pathogen and the environment. The host is us; our population is younger. There were also other unproven theories about the BCG vaccine or immunity through an earlier version of a coronavirus. But nothing is known. Then the environment – it is a well-established fact that ultraviolet light kills microorganisms. This is a theory, but it cannot explain what happened in Brazil. Don’t forget communication – the media got our message across. Everyone had doubts in the beginning, but once the pattern was clear, the disbelief went away.

A: There is criticism that Pakistan has not been as proactive in obtaining the vaccine compared to other countries in our region.

FS: Until about a week ago, there were about 65 countries where vaccination rollouts had begun and 130 have yet to begin. Pakistan began its programme 24 days ago. So, we cannot say we began late and you cannot compare us to countries like the US, a 150-year old democracy that put a man on the moon in 1969.

A: India began earlier as well.       

FS: When the Serum Institute of India (where the vaccine is manufactured) was established, what were we doing? This is the question we need to ask. We cannot change the past. We were able to leverage our friendship with China and begin the programme. Availability of the vaccine is not the issue; our problem is hesitancy and we are not alone in this. By the end of June, we will have 17 million doses; the challenge is to deploy and use them. The number of people who have registered is in the hundreds of thousands, not millions, yet we need to vaccinate 40 to 50 million by the end of this year.

A: Why hasn’t the government launched an awareness campaign to encourage vaccination?

FS: It is coming. We will begin a mass campaign in March after the vaccine arrives; there is no point creating hype when we don’t have it.

A: Are you worried about a third wave?

FS: There can be a third wave in the world in the coming winter. However, with enough vaccinations combined with the number of people who have already caught it may provide a community level of immunity. However, the variants are a threat. In my opinion, we may have seen the worst of it, but the coming winter will tell the real story.

A: Apart from the pandemic, what is on your health agenda?

FS: We have six or seven fundamental goals. Healthcare delivery, eliminating preventable diseases, malnutrition, access to high-quality pharma, a quality health workforce; we had a reputation for good doctors; is this still true? I don’t think so. There is a shortage of nurses; we need a million nurses. Let’s first talk about healthcare delivery reform – the Medical Teaching Institutions (MTI) Act 2020 has been furiously debated. In essence, all we are doing is that instead of the head of say the Pakistan Institute of Medical Sciences (PIMS) or Khyber Teaching Hospital or Mayo Hospital reporting to a joint secretary, they will report to a board made up of competent people and they will have the flexibility to decide what their budgets should be used for – is it needed for chairs or tables or injections – and they will be able to reallocate, which isn’t possible under the present system. They will be provided with a budget and an accountable performance-driven system. When you introduce change to an entrenched system, there is resistance. There was a strike at PIMS but we engaged with them; they had some fair demands and we will implement them in the federal hospitals.

A: The government’s experience with independent boards has not worked out in the past in other sectors.

FS: The choice of the people who are appointed to these boards is crucial. It is a three-step process. There is a search and nomination council (which will also be nominated) that will nominate the board which will be approved by the cabinet (provincial or federal). There has been an effort for transparency. Once the board is formed, we will provide the benchmarks for quality, safety and performance. In KPK, the health commission hired a third party to audit three hospitals and it is working. These hospitals are much better governed today after four years of opposition and people have realised it can work; it’s not perfect, but managing hospitals is not easy. We are also going to reform the primary and secondary system here as well as in the provinces. We want to create a governing entity for the entire primary and secondary system, which will include the hospitals that do not come under the MTI Act. As for universal health, diseases such as cancer or kidney failure,make people poor. Hence, we intend to provide coverage for these illnesses. We began in KPK; people in the Ehsaas Programme below a certain cut-off limit were allowed a finite set of procedures from empanelled hospitals. Every household received a card with a limit of a million rupees. This will be a major game-changer in healthcare delivery. We have begun the process at the federal level and we are talking to the Punjab Government. The idea is that everyone should have a health card for coverage in the named hospitals. 

A: Will this be a sustainable burden on the exchequer?

FS: We spend a lot more than this amount on other projects. In the larger scheme of things, it is not such a big number. However, it needs to be managed; oversight and transparency have to be ensured. It will become more expensive over time but then the state needs to take care of the weakest segments of society. It is an investment in our future and our people. We will be saving lives and improving the people’s trust in a democratic Pakistan. One needs to exercise caution with what diseases and procedures are covered and the provinces have to provide the oversight. This can also be used to change behaviour – for example, doctors prefer to carry out C-sections to deliver babies but we have kept the cost of a natural delivery nearly as high as a C-section, so if hospitals want to keep their bottom-line in mind, they will do a C-section only when necessary.

A: What if the provinces do not manage to create the oversight?

FS: The oversight will be in Islamabad; it is a federal programme.

A: Despite criticism, you have maintained that the increase in the price of drugs is the way forward. 

FS: The problem is that we are importing the active ingredients that go into medicines and packaging them here. So how can we be unaffected by global prices? Prices fluctuate in the global market while prices are fixed in Pakistan. Over time, the people importing these medicines will stop doing so. While we resist selling a drug for Rs 12 instead of Rs 10, it is available for Rs 50 on the black market. The bigger issue is that DRAP (Drug Regulatory Authority of Pakistan) has to enter the modern world. After a Supreme Court Order, DRAP has to regulate devices as well as drugs; from lenses to pacemakers to stents. Hence, a complete overhaul of the DRAP Act is planned and we have to encourage the manufacture of active ingredients in Pakistan, which will protect local consumers from external price changes.

A: How will this be encouraged?

FS: We have to provide space; ensure reasonable prices, a volume of sales and register new products. If we manufacture the active pharmaceutical ingredient in Pakistan, the medication may cost Rs 80 instead of

Rs 100 when imported. You have to allow the industry to see the light at the end of the tunnel and not squeeze them on price. If we invest in manufacturing, we will not only serve a large market in Pakistan, we will also allow certification so that high stringency countries will be able to buy our products. If DRAP can meet the same kind of certification standards as regulators do elsewhere, then the sale of the medicines we manufacture in Pakistan will not be restricted to developing countries. The difference is having a credible certification. At the moment, DRAP is going through the process of certifying itself and at the same time, we need to ensure that the manufacturing companies are investing in quality.

This will not happen overnight, but we have to begin with DRAP.

A: This will require massive legislation.

FS: Yes. It is around the corner. Some of it has happened – the Pakistan Medical Commission Act and the Medical Teaching Institute Act have been enacted; others will in the coming days. 

Dr Faisal Sultan was in conversation with Arifa Noor. (Arifa Noor is a journalist and the lead anchor for NewsWise on DawnNews.arifanoor@gmail.com)