Joint External Evaluation of IHR Core Capacities of the Islamic Republic of Pakistan

Mission report: 27 April – 6 May 2016

Joint External Evaluation of IHR Core Capacities of the Islamic Republic of Pakistan

Mission report: 27 April – 6 May 2016 WHO/WHE/CPI/2017.9

© World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules). Suggested citation. Joint External Evaluation of IHR Core Capacities of the Islamic Republic of Pakistan. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permis- sion from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recom- mended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by Jean-Claude Fattier Printed by the WHO Document Production Services, Geneva, Switzerland ACKNOWLEDGEMENTS

The WHO JEE Secretariat would like to acknowledge the following, whose support and commitment to the principles of the International Health Regulations (2005) have ensured a successful outcome to this JEE mission: • The Government and national experts of the Islamic Republic of Pakistan for their support of, and work in, preparing for the JEE mission. • The governments of Australia, Egypt, Finland, Greece, Lebanon, Morocco, Saudi Arabia, the United Kingdom, and the United States of America, for providing technical experts for the peer review process. • The Food and Agriculture Organization of the United Nations (FAO), and the World Organization for Animal Health (OIE) for their contribution of experts and expertise. • The governments of Germany and Finland for their financial support to this mission. • The following WHO entities: WHO Country Office of Pakistan, WHO Regional Office for Eastern Mediterranean, WHO Regional Office for Europe, WHO HQ Department of Country Health Emergencies Preparedness and IHR. • Global Health Security Agenda Initiative for their collaboration and support.

Contents

Abbreviations------iv Introduction------1 Executive summary------3 Pakistan scores------7 PREVENT—————————————————————————— 9 National legislation, policy and financing------9 IHR coordination, communication and advocacy------12 Antimicrobial resistance------14 Zoonotic diseases------17 Food safety------20 Biosafety and biosecurity------23 Immunization------26 DETECT————————————————————————— 30 National laboratory system------30 Real-time surveillance------33 Reporting------38 Workforce development------40 RESPOND ———————————————————————— 44 Preparedness------44 Emergency response operations------48 Linking public health and security authorities------54 Medical countermeasures and personnel deployment------57 Risk communication------60 OTHER—————————————————————————— 65 Points of entry------65 Chemical events------69 Radiation emergencies------73 Reports on provinces and federating areas------75 Sindh------75 Punjab------77 Khyber Pakhtunkhwa------80 Balochistan------82 Islamabad Capitol Territory------84 Gilgit-Baltistan------86 Azad Jammu and Kashmir------87 Federally administered tribal areas------88 Annex: Joint external evaluation background------89 vi Joint External Evaluation IHR IEC IDSR ICT HRH HEPRN HCAI GOARN GHSA GB Gilgit-Baltistan GAP FP FAO FELTP FATA EQAS EPR EPI EPA EOC EMR EET DSS DoCHE DHIS DEWS C CCHF CADD BSL AMR AJK AFP Abbreviations DA

International Health Regulations information, educationand communication integrated diseasesurveillanceandresponsesystem Capital TerritoryIslamabad human resourceforhealth health emergencypreparednessandresponsenetwork health care-associatedinfections Global Outbreak Alert andResponse Network Global HealthSecurity Agenda WHO Global Action Planforinfluenza vaccines focal point Food and Agriculture OrganizationoftheUnitedNations Field EpidemiologyandLaboratory Training Programme federally administeredtribalareas external qualityassurance scheme emergency preparednessandresponse Expanded Programme forImmunization Protection Agency Environmental emergency operations centre WHO EasternMediterranean Region external evaluation team disease surveillancesystem Directorate ofCentral HealthEstablishments district healthinformationsystem disease earlywarning systems Development Authority Capital Crimean-Congo haemorrhagicfever Capital Administration andDevelopmentDivision biosafety level antimicrobial resistance Azad Jammu andKashmir acute flaccidparalysis WHO VPD VLMIS VHF UV UNICEF TB tuberculosis SOP SARI T RR PVS PPE Po PNRA PDMA OIE NRLPD NIH NHSR&C NHEPR NGO NFP NDMA NARC NAPHIS MERS-CoV) JEE ISO IL E AS

points ofentry World HealthOrganization vaccine-preventable disease Vaccine LogisticsManagementInformationSystem viral haemorrhagicfever University of Veterinary and Animal Sciences United NationsChildren’s Fund standard operating procedures severe acuterespiratory infection rapid responseteam performance ofveterinaryservices Personal protectiveequipment Pakistan NuclearRegulatory Authority Provincial DisasterManagement Authority World Organisationfor Animal Health National ReferenceLaboratory forPoultry Disease National InstituteofHealth National HealthServicesRegulationsandCoordination(Ministryof) National HealthEmergencyPreparednessandResponseNetwork nongovernmental organization National Focal Point National DisasterManagement Authority National Agricultural ResearchCentre National Plant, Animal HealthandInspectionService Middle Eastrespiratory syndromecoronavirus Joint ExternalEvaluation oftheIHR International OrganizationforStandardization influenza-like illness v of IHR Core Capacities of the Islamic Republic of Pakistan

On 30June2011, the18 domestic product(GDP). 2015–2016). The budgetaryallocationforthehealthsectorhasconsistentlyremained below1%ofgross Pakistan isaround180million, withapercapitayearlyincomeofUS$ 1560 (EconomicSurveyofPakistan, areas (FATA). These provinces/administrative areasvary intheirlevel of development. The populationof Islamabad capitalterritory(ICT), Stateof Azad Jammu andKashmir(AJK)federally administered tribal and four federating areas: Gilgit-Baltistan (GB, province-like status under 2009 presidential ordinance), Pakistan isafederal systemcomprisingfourprovinces: Baluchistan, KhyberPakhtunkhwa, PunjabandSindh; health systemthatwillmeetthestandardsforIHR. The findingsoftheevaluation willguide Pakistan infinalizingits5-yearroadmapto developastrongpublic Mediterranean Region, andthefourthglobally, volunteeredforaJointExternalEvaluation. and monitortheimplementationofIHR(2005), Pakistan asthefirstcountryin WHOEastern In responsetoresolutionEM/RC62/R.3oftheRegionalCommittee WHO EasternMediterranean toassess monitoring andevaluation. developed aJointExternalEvaluation (JEE)toolasoneoffourcomponentsanew framework forIHR The WHO Secretariat, withinputfrompartners, includingtheGlobalHealthSecurity Agenda, subsequently approach fortheassessmentandmonitoringofIHRimplementation. session, the WHO RegionalCommitteefortheEasternMediterranean Regionhaddiscussedsuchanew Framework was noted by the 69th World Health Assembly. As soon as October 2015, during its 62nd was discussedbythe WHO RegionalCommitteesin2015, andarevisedIHRMonitoringEvaluation a combinationofdomesticandindependentexperts.” A conceptnoteoutliningthisrevisedapproach to approachesthatcombineself-evaluation, peerreviewandvoluntaryexternalevaluations involving IHR Implementation(WHA68/22 Add.1) recommendedin2014 “to movefromexclusiveself-evaluation The IHRReviewCommitteeonSecondExtensionsforEstablishingNationalPublicHealthCapacitiesand internally orexternally. detect andrespondtohealththreatsprotectitspopulation, irrespectiveofwhetherthethreatsarise the country’s travel andtrade. Evenmoreimportant, itmeansthecountryisnotfullypreparedtoprevent, However, despitemultipleefforts, ithasyettomeettherequiredcorecapacities, whichcouldjeopardize The IslamicRepublicofPakistan isasignatorytotheInternationalHealthRegulations–IHR(2005). Introduction of Pakistan’s futuresuccesstoachievecompliancewith theIHR. the populationwas unequivocal. This continuedcommitmentwillbeacriticaldeterminant andcomponent areas. Throughout theevaluation, thecommitmentofallpartiestoworktogether improvethehealthof this JEEfocusedonassessmentofcapacitiesatboththe nationallevelandintheprovincial/federating implementation ofhealthsectorstrategies andplansare, however, aprovincialresponsibility. Therefore, obligations, includingUnitedNationsSustainableDevelopment GoalsandIHR. The developmentand research, nationalreportingforthehealthsector, establishingqualitystandardsandmeeting international a visionforthehealthsector, interprovincialcoordination, regulationinmedicalandallied education, under federal legislativelistI and II. Initsstewardship role, theMinistryisresponsiblefordeveloping Regulations andCoordination(NHSR&C)was establishedon4May2013withspecificrulesofbusiness of Healthanddevolvedhealthissuestotheprovincial level. The MinistryofNationalHealthServices th Amendment totheConstitution ofPakistan abolishedtheFederal Ministry 1 of IHR Core Capacities of the Islamic Republic of Pakistan 2 Joint External Evaluation provided undereachofthetechnicalareasectionsthisreport. Technical areascores, supportinginformation, andspecificrecommendationsforpriorityactionsare the IHRasdescribedinJEEtool. between theEETandtheirPakistani peersrepresentingallthesectorsrelevant tothe19technicalareasof This reportpresentsjointlydevelopedrecommendationsandpriorityactionsthatresultedfromdiscussions for thecitizensofPakistan. efficiencies, createopportunities, andformthefoundationofaworld-class, equitablesystemofhealthcare collaborate effectivelywas apparentthroughouttheassessment. This dialogueonbothsideswillmaximize The mutualcommitmentofthefederal governmentandtheprovincialgovernmentsfederating areasto 1 coordination acrossmultiplesectorsfora “One Health” approach. devolution scenariointhecountry, particularly theopportunitytooptimizefederal andprovincial The timing of the JEE is optimal given international attention to global health security and the post- Major findings This summaryhighlightstheimportantcross-cuttingthemesthatemergedasprioritiesforaction. of national, provincialandfederating areaperspectives. areas. The follow-up meetings and site visits in Islamabad and four major provinces ensured representation need strengthening/challenges, scores, andrecommending3–5priorityactionsforeachofthe19technical in aseriesoffacilitateddiscussionstojointlyassessPakistan’s currentstrengths/best practices, areasthat EET atthestartofexternalassessmenton27 April. The EETandhostcountryexpertsthenparticipated The resultsoftheself-assessmentforalltechnicalareaswerepresentedanddiscussedindetailwith disaster managementauthorities, andthePakistan Atomic EnergyCommission. environment and climate change sectors, food security, livestock, agriculture, national and provincial from thenational, provincialandfederating areas. Participants includedrepresentativesfromhealth, JEE tool. Two intenseorientationsessionswereconductedinKarachi andLahorefor120participants work atnationalandprovincialleveltocompiledatainformationonall19technicalareasinthe of Pakistan completedaself-assessmentusingtheJEEtoolfollowingfourweeksofrigorouspreparatory experts atboththenationalandprovinciallevel. Priortothearrival oftheexternalteam, theGovernment The Joint External Evaluation was based on completely collaborative, multisectoral discussions with country assessment. The missiontookplacefrom April 27to6 May2016. recognized technicalexpertisefromanumberofcountriesandinternationalorganizationsconductedthe (JEE) tool. A multisectoral international External Evaluation Team (EET) selected on the basis of their the IslamicRepublicofPakistan usingthe World HealthOrganization(WHO)IHRJointExternalEvaluation This evaluation was ajointassessmentofInternationalHealthRegulations(2005)(IHR)corecapacities Executive summary • threats. fulfil the IHR requirements to prevent, detect and mount a comprehensive public health response to health Five majorcross-cuttingthemesemergedfromthereview ofthe19technicalareasthatarerequiredto care deliverythroughoutPakistan. opportunity toreplicatetheexperiencesandbestpractices ofmoreadvanced areastostrengthenhealth- sectors arequiteadvanced while othersarecurrentlylessso. This diversityisachallengebutalsoan Significant differencesexistincapacitytoprovideprimaryandpreventivehealthcare. Someareasand country’s commitmenttopublichealth, giventhatPakistan isonthevergeofpolio eradication.

dia/onehealth/ interdependent andboundtothehealth oftheecosystemsinwhichtheyexist. World Organisation for Animal Health, www.oie.int/en/for-the-me- The “One Health” conceptwas introducedatthebeginningof2000s. Inafew words, itsummarizesthathumanhealthandanimalare government and provincial authorities. The devolution and subsequent renotification of the Ministry but not limited to public health, animal health, security, and environment) the and federal between This coordination. extendsin and all (including directions sectors communication –between F irst and foremost, there is a critical need for continued and expanded multisectoral multisectoral expanded and continued for need acritical is there foremost, and irst 1 Itisalsotimelybecauseitreflectsthe 3 of IHR Core Capacities of the Islamic Republic of Pakistan 4 Joint External Evaluation • • The followingareoverarching, highpriorityactionsforimplementingtheresultsof this assessment. Next steps 2 • • • •

essential publichealth measures. The NIH, asassessed bytheEET, doesnotcurrentlyfulfilallcriticaltaskscharacteristic ofapublichealthinstituteorfor theimplementationof T evaluation. external the by facilitated together to build on the goodwill for collaboration developed through the self-assessment process, the current governmental mandate and framework as it essentially involves gettingthe right people “One Health” approach in order to build the requisite IHR core capacities. This done canbe within enhance the scope and representation of this Task Force to include relevant stakeholders in astrong and provincialsectors representation is already established and in place. There is however, aneed to provinces and the federal ministry. The National IHR Task Force comprising health and non-health coordination strengthen mechanisms and establish Immediately restricted by current legislation and administrative orders. system and processes in order to institute them without delay. However, most actions appear to be Public Health Institute Public Health safety, with appropriate infrastructure, at national and provincial levels. The development of a National system, health laboratory T responsible implementing authorities/stakeholders. establishing afunctioning public health laboratory in each province within three years) and identifythe identified across the 19 technical areas.The roadmap should include clear milestones (forexample The roadmapsupport. will also provide the core platform to develop actionplans for the key priorities priorities for implementation and negotiation with internal and external for partners investment and National and Research, Security Food Ministry of Climate Change and other stakeholders to agree on This plan will provide the basis for the Government of Pakistan, the Ministry of NHSR&C, Ministry of and multisectoral process like the JEE assessment will strengthen buy-in and commitment at all levels. Use of an capabilities. open, IHR transparent, to strengthen plan/roadmap fully collaborative 5-year country supported widely funded, asufficiently for need acritical is there Second, which to build collaboration effective and coordination. system, clarity on the roles and responsibilities at all levels is critical to success and forms the basis on of each. Work to define roles and responsibilities shouldbe continued: in any devolved or federated opportunities by establishing the regulatory base, structures and systems that maximize the strengths of NHSR&C has created both challenges and opportunities. Pakistan has begun to capitalize on the resistance and control of health care-associated infections. F contamination. microbiological and chemical for food safety, mechanisms F framework. the implementing level provincial the and consultation, approach to devolution in Pakistan with the national level the setting policy and framework in mutual “One Health” approach. The organization of the surveillance system could modelled be on the overall ask the M the ask to managing antimicrobial antimicrobial managing to approach cross-sectoral anational for aneed is there ifth, ourth, there is a need to develop and enhance regulations, standards, and coordination coordination and standards, regulations, to develop a is need enhance there and ourth, hird, there is a need to establish a strong, visible, active surveillance and tiered public and surveillance active visible, a strong, to establish aneed is there hird, inistry of N of inistry 2 might meet this criterion, but would need to considered be in the context of a H SR& covering human and zoonotic animal health as well as food and water from the beginning to end of the production chain, addressing both for framework the legal the new in gaps any C to identify across sectors and between and across between sectors • – – – – – – – will underpin be actions for all technical areas. veterinary (PVS) services pathways). The following themes will need to taken be into account, as they into the plan the recommendations of previous international assessments such as the performance of F using the JEE report as the basis for priority actions (building actions basis the as using for priority JEE the roadmap report 5-year inalize the cost and – – – – – – – and longer term perspective. term longer and improvement. The JEE therefore is one step along this process and should include both a wider health people, of its it is not an end in itself; it is of a process the start of continuous review and theme is that, although evaluation is an essential step to improve acountry’s ability to protect the implementation),its and the response to international evaluation of the Ebola response. A common evolution of the Global Health Agenda Security (formed of the based on IHR article to 44 support process (of which the JEE is an integral part), the OIE Performance of Veterinary the Services, Reduction, WHO’s emergency response reform and the restructuring of the IHR’s monitoring and of is otherIt supports apart processes such as the Sendai Framework for Disaster Risk the external JEE years. in The JEE 3–5 is acontinuous process of evaluation and improvement. C the international community will countries support in need. global health process security that countries will help each other and that agencies and donors of and visibility, makes it ideally suited for this purpose. There is an inherent presumption in the The multisectoral and collaborative nature of the JEE process, which enjoys broad global support international agency, donor and technical to support the plan/roadmap country and priorities. its support: technical and E investment is needed, which should come from acombination of domestic and external support. completed within be existing resources, can additional but actions number A sought. priority of F applying the incident management system approach should established. be preparedness: Cross-sector immediately. developmentstart should not depend on completing the legislative reform but rather initiated be national and provincial Health Emergency Preparedness and Response Plans. However, to efforts the and consideration, under legislation currently (NAPHIS) Service Inspection Plant Health and Animal National the diseases, notifiable legislation for include plans. Examples legislation and examine the need to accelerate finalization and approval of important national and provincial and Justice to identifywhether gaps exist in the legislative system tothe roadmap support and L more generic horizontal system capable of detecting and responding to any disease. the integrated infectious disease surveillance and control system should developed be toward a generally, surveillance. More disease vaccine-preventable immunization and particularly priorities, practices of polio eradication are transitioned and mainstreamed over time toother support P retention for various public of categories and animal health professionals. needs, eligibility criteria, efficient recruitment, and developmentcareer of a ladder to improve provincial levels. There is aneed for human resource policies and strategies that include projected Workforce development: egislative The Ministry gaps: of NHSR&C should initiate areview with the Ministry of Law unding: ngagement and coordination with external partners to fill gaps in financial financial in to fillgaps partners external with coordination and ngagement olio eradication transition: eradication olio ontinual improvement: Pakistan improvement: ontinual should institute annual JEE self-evaluation and repeat Domestic and technical funding for the plan/roadmap country should allocated be or This should report as acommon serve platform for coordination of This is amajor challenge highlighted at both the federal and Cross-sector preparedness and response for all capacity hazards Systematic planning must determine how the and assets best 5 of IHR Core Capacities of the Islamic Republic of Pakistan

Pakistan scores Source: Indicator tablesoftheJointExternalEvaluation Tool, IHR(2005) MonitoringandEvaluation Framework. 1 Red: nocapacity; yellow: developedordemonstrated capacity; green: sustainable capacity. Biosafety andbiosecurity Antimicrobial resistance Workforce development Real-time surveillance National legislation, policy andfinancing policy communication and communication National laboratory IHR coordination, Zoonotic diseases Immunization Capacities Food safety Reporting advocacy system of relevant intheimplementation sectors ofIHR. P.2.1 mechanismisestablishedforthecoordination Afunctional andintegration D.3.1 System forefficient to reporting WHO, FAO andOIE government instruments inplace are sufficient forimplementation ofIHR P.1.1 Legislation, laws, regulations, administrative requirements, policiesorother P.3.1 Antimicrobial resistance (AMR) detection D.2.1 Indicator andevent systems basedsurveillance man, animal, andagriculture facilities P.6.1 system isinplace andbiosecurity forhu- biosafety Whole-of-Government D.1.4 System Quality Laboratory D.1.3 Effective modernpoint ofcare baseddiagnostics andlaboratory D.1.2 Specimenreferral system andtransport P.7.2 National vaccine access anddelivery P.6.2 training andpractices andbiosecurity Biosafety lished andfunctional P.4.3 Mechanismsforresponding to zoonoses andpotential zoonoses are estab P.4.2 Veterinary orAnimalHealth Workforce P.3.4 Antimicrobial stewardship activities P.3.3 Healthcare prevention associated (HCAI) infection andcontrol programs P.3.2 causedby AMR pathogens ofinfections Surveillance the IHR(2005) legislation, policiesandadministrative arrangements to enablecompliance with P.1.2 The state candemonstrate that ithasadjusted andaligneditsdomestic D.4.3 Workforcestrategy training programme inplace D.4.2 Field epidemiologytraining programme orotherappliedepidemiology D.3.2 network andprotocols Reporting incountry D.2.4 Syndromic systems surveillance D.2.3 data Analysisof surveillance D.2.2 Inter-operable, interconnected, real-time electronic system reporting foodborne diseaseandfoodcontamination. P.5.1 andresponding fordetecting Mechanismsare to establishedandfunctioning P.7.1 Vaccine coverage ofnational program (measles)aspart D.1.1 diseases testing ofpriority Laboratory fordetection P.4.1 systems zoonotic inplace Surveillance forpriority diseases/pathogens D.4.1 Humanresources are available to implement IHRcore requirements capacity Indicators - Score 3 3 1 1 1 1 3 3 2 2 3 3 2 2 4 2 2 3 2 2 3 4 4 2 2 2 2 2 1 7 of IHR Core Capacities of the Islamic Republic of Pakistan 8 Joint External Evaluation for eachparty’s position. Lead willdecideonthefinal scoreandthiswillbenotedintheFinalReport, along withthejustification country expertsoramongtheexternalhost countryexperts, theExternalEvaluation Team there besignificantandirreconcilabledisagreementbetween theexternalteammembersandhost collaborative, withexternalevaluation teammembersandhostcountryexpertsseekingagreement. Should around thescore, thestrengths, theareaswhichneed strengthening, andthepriorityactionsshouldbe on-site consultation with the external team. The entire external evaluation, in particular the discussions included intheJEE Tool. The hostcountrymayscoretheirself-assessmentorproposescoresduringthe to focusonprovidinginformationtheircapabilities based ontheindicatorsandtechnicalquestions step intheJEEprocess, andaspartofpreparing for anexternalevaluation, hostcountriesareasked host countryexpertsandExternalEvaluation Team members. Incompletingtheself-evaluation, thefirst The JointExternalEvaluation processisapeertoreview. As such, itisacollaborative effortbetween Note onScoringoftechnicalareas oftheJEE Medical countermeasures Medical Linking publichealthand Radiation emergencies Emergency response Emergency Points of entry (PoE)Points ofentry Risk communication security Authorities security Chemical eventsChemical and personnel Preparedness deployment operations R.2.1 Capacityto activate operations emergency chemical events oremergencies andresponding fordetecting CE.1 Mechanismsare to establishedandfunctioning Plan isdeveloped andimplemented R.1.1 Multi-hazard National Public Health Preparedness Emergency andResponse a publichealthemergency R.4.1 System isinplace forsendingandreceiving medicalcountermeasures during R.1.2 Priority publichealthrisksandresourcesR.1.2 Priority are mappedandutilized RE.2 Enabling environment isinplace formanagement ofradiation emergencies CE.2 Enabling environment isinplace formanagement ofchemicalevents PoE.2 Effective publichealth response at Points of Entry listening andrumourmanagementR.5.5 Dynamic R.5.4 Communication engagementcommunities withaffected R.5.3 Public communication communicationR.5.2 Internal andcoordination andpartner health emergency R.4.2 System isinplace forsendingandreceiving healthpersonnelduringapublic R.2.4 Case management procedures are implemented forIHRrelevant hazards operationsR.2.3 Emergency programme OperationsR.2.2 Emergency Centre operating procedures andplans R.5.1 Risk communicationR.5.1 Risk systems (plans, mechanismsetc.) radiological and nuclearemergencies andresponding fordetecting RE.1 Mechanismsare to establishedandfunctioning PoE.1 Routinecapacitiesare establishedat PoE. customs) are linkedorconfirmed biologicalevent duringasuspect authorities(e.g.R.3.1 Public healthandsecurity law enforcement, border control, T ool: 2 2 2 1 4 4 3 2 3 2 2 1 1 5 5 2 2 2 2 3 National legislation, policy andfinancing National legislation, policy Introduction are important. identify nationalstructuresandresponsibilitiesaswelltheallocationofadequatefinancialresources legislation at http://www.who.int/ihr/legal_issues/legislation/en/index.html. In addition, policies which entities involved in their implementation. See detailed guidance on IHR (2005) implementation in national of IHR(2005)andoperations withintheStateParty. Itcanalsofacilitatecoordinationamongthedifferent in amoreeffectivemanner. Implementinglegislationcouldservetoinstitutionalizeandstrengthentherole may stillchoosetorevisesomeregulationsorotherinstrumentsinorderfacilitateIHRimplementation of existinglegislativeinstruments. Evenifneworrevisedlegislationmaynotbespecificallyrequired, States States Parties, implementation of the IHR (2005)mayrequire new or modified legislation or simply theuse States Parties should have an adequate legal framework to support and enable the implementation of of implementation the enable and support to framework legal adequate an have should Parties States 1 regulatory assessmenttoidentify allareasforimprovement. for IHR. The bestpractice to ensureacomprehensivelegalframework wouldbetoconductalegaland inevitably somegaps, overlaps andareasforimprovementinthenationalprovincial legallandscape (2005), andthefactthatnationalprovinciallegal landscapehasmultiplerelevant laws, thereare Given the fundamental changes to the Constitution since 1973, the structure of Government since the IHR practice forcountriestotake into consideration forIHRcoordination. business thatdefinetheresponsibilitiesofeachministry. This legalframework isagoodexampleofbest contain mechanismsforcoordinationbetweenthedifferent partsoftheGovernmentandrules The legalframework forIHRcoordination derivesfromthe1973Constitutionanditsamendmentsthat require intensetimeandeffort. foundation for IHR implementation, obviating the need for parliamentary approval – a process that can instruments suchasregulationsorotheradministrative measuresthatcanprovidethe necessarylegal Although somenewlegislationmightbeneeded, overall thecurrentlegalsystemprovides numerouslegal of medicines, health-careservices, healthprofessionals, foodsafetyandportsofentryamongothers. of IHRandtheGlobalHealthSecurity Agenda (GHSA)technicalareastargets. Laws governtheregulation Pakistan hasasubstantialnationalandprovinciallegalframework tosupportandenable theimplementation P T The InternationalHealthRegulations-IHR(2005)providesobligationsandrightsforStatesParties PREVENT all of their obligations and rights to comply with and implement the IHR (2005). In some States Parties, Parties, States some In (2005). IHR the implement and with comply to rights and obligations their of all implementation of the IHR (2005) may require new or modified legislation. Even where new or revised revised or new where Even legislation. modified or new require may (2005) IHR the of implementation legislation may not be specifically required under the State Party’s legal system, States may still choose choose still may States system, legal Party’s State the under required specifically be not may legislation to revise some legislation, regulations or other instruments in order to facilitate their implementation implementation their facilitate to order in instruments other or regulations legislation, some revise to and maintenance in a more efficient, effective or beneficial manner. State parties should ensure ensure should parties State manner. beneficial or effective efficient, more a in maintenance and provision of adequate funding for IHR implementation through national budget or other mechanism. other or budget national through implementation IHR for funding adequate of provision

http://nhsrc.gov.pk/ ->DownloadsLaws, SROs andNotifications arget akistan levelofcapabilities

1 . Insome

9 of IHR Core Capacities of the Islamic Republic of Pakistan PREVENT 10 PREVENT

Joint External Evaluation • • • This reportrecommendsthefollowingpriorityactionstofulfilobligationsofIHR. Recommendations forpriorityactions 2 • • • • practices trengths/best S and othergovernmentinstrumentsforIHRimplementationhasbeencarriedout. Score 2: Limitedcapacity. Assessmentofrelevant legislation, regulation, administrative requirements instruments inplaceare sufficientforimplementationofIHR. P Indicators andscores

.1.1 Legislation, laws, regulations, administrative requirements, policiesorothergovernment http://nhsrc.gov.pk/ ->DownloadsLaws, SROs andNotifications – – – term long and medium the in recommendation the of Implementation – – – term near the in recommendation the of Implementation implementation. – to ensure the laws relevant to non-health stakeholders sector are consistent and supportive of IHR essential to IHR –the judiciary, agriculture, food safety, transportation, aviation, tourism, the police Government by clearly definingstakeholders andbodies of law outside the health thatsector are where possible. This assessment should follow the “One Health” approach across the whole of if already present, identifygaps, adjust laws or where adopt administrative necessary arrangements public health activities needed to implement fully the IHR: determine the legal authority needed and, Conduct alegal and regulatory assessment jointly by public health to and define legalthe experts accessible to the general public. general the to accessible The Ministry publishes laws and actively maintains awebsite with acomplete repository of laws and Justice, and acapable private legal that sector canprovide short-term technical legal expertise. Pakistan has asenior, knowledgeable lawyer assigned to public health matters in the Ministry of Law A substantial legal framework for exists most technical areas. undertaken in 2010 and 2012–2013. In addition, evaluation aPVS was conducted in 2015. in 2013 and alegislative assessment of the existing rules and laws related to public health were Pakistan demonstrates commitment to implementing the IHR; in addition to this JEE, an IHR assessment – – – – – – Reinforce IHR implementation linked to health system strengthening. strengthening. linked system health to implementation Reinforce IHR Pass new and pending legislation as needed, and coordination overall IHR of part as arrangements Align and harmonize national, interprovincial, and provincial laws, policies and administrative Approve and implement outstanding policies outstanding implement and Approve international and domestic legal technical assistance until an internal legal unit is functional Build alegal unit in the Ministry of National Health training Services, senior through staff Use administrative legal tools to address IHR stipulations that require alegal foundation 2

3 A chartofthelawsfor19technicalareasatnational andprovinciallevelisavailable uponrequest. documentation Relevant • • • strengthening/challenges need that reas A • • • practices trengths/best S policies inthevarious sectorsinvolvedintheimplementationofIHR. Score 3: Developedcapacity. The countrycandemonstrate theexistenceanduseofrelevant lawsand policies andadministrative arrangements toenablecompliancewiththeIHR(2005). P • • • strengthening/challenges need that reas A

.1.2 regulation, andcard IV-2: Implementationoflegislation andregulationcompliancethereof. For theanimalhealthsector, thisinformationcanbefoundinthecountryPVSreport, CriticalCompetenciescardIV-1: Preparation oflegislation and line and funding need to approved be toIHR implementation. support budget allocations for the IHR in the regular or development budget in the past. Adedicated budget specific no with fragmented been has response emergency and surveillance IHR/disease for Funding implemented. and billsDraft and policies need to reviewedbe and approved by Parliament and other relevant authorities, public health, there is aneed for adedicated legal unit within the Ministry of NHSR&C. Coordination. Although one senior from the staff/lawyer Ministry of Lawand Justice is assigned to There is insufficient legal thecapacity to Ministry support of National Health Services Regulation and system. reporting and surveillance integrated and coordinated framework to include health establishments and health (human and animal) professionals into a commissions, aDrug Regulatory Authorityand professional councils. These will provide the legal Pakistan is in the process of building astronger regulatory system by establishing health-care regulation. health biosafety and biosecurity, and national laboratories; and bills draft on food safety, animal and plant Progress has been made to develop and approve policies and bills, draft for example policies on AMR, National IHR Focal Point (NFP). IHR is entrusted to the Ministry of National Health Regulation Services and Coordination (including the (AMR). resistance antimicrobial and diseases zoonotic priority address to programmes surveillance animal health and the health under sector the umbrella of the “One Health” approach (e.g. coordination human between Multisectoral coordination stakeholders between should strengthened, be especially with those outside beneficial. be would instruments legal and awareness training of health and technical staff and to efficiently support effectively existing use of Parliament,Acts and are thus unable to advise on the range of legal options available. Advocacy unfamiliarMinistry staff with the legal framework incorrectly presume that legislation only concerns should provide technical to support plug these gaps. Some provinces lack laws in essential areas such as food safety. Provinces that already have such laws The statecandemonstrate thatithasadjustedandaligneditsdomesticlegislation, 3 11 of IHR Core Capacities of the Islamic Republic of Pakistan PREVENT 12 PREVENT

Joint External Evaluation The effective implementation of the IHR (2005) requires multisectoral/multidisciplinary approaches through through approaches multisectoral/multidisciplinary requires (2005) IHR the of implementation effective The T IHR andadvocacy coordination, communication sectors intheimplementationofIHR. P Indicators andscores Recommendations forpriorityactions practise andexecutetheseelementslocallyintimesofneed. Gilgit-Baltistan. Noneoftheprovincesorfederating areashasinplaceamultisectoral OneHealthbodyto event arealsolacking. All provinceshaveanIHRfocalpointexceptforthe Azad Jammu and Kashmir and application andpractice ofkey elementsofIHRatprovincial/federating arealevelsinresponsetoathreat/ may accruetoothersectorsfromsuchmultisectoral coordinationarelacking. Furthermore, postdevolution, and sustainablelinkagesbasedonaclearunderstandingofthesignificanceIHRbenefitsthat other lineministriesatfederal andprovinciallevelsneedtobemaintained. However, institutionalized an IHRmultisectoral Task Force thatmeetsperiodically. Advocacy sessionshavealsobeenconductedfor The MinistryofNHSR&ChasdesignatedanIHRNFPaccessible24/7and, togetherwith WHO, hasestablished maritime, commerce, etc.)iseitherlackingorlimitedatalllevels. health, (humanandanimal)withcriticalnon-healthsectors(trade, transportation, tourism, aviation, Ministry ofNHSR&CisthecustodianIHRimplementation. However, linkagesandcoordinationwithin health relatedsectorsremainunevenatbest. Inmostinstances, theformerMinistryofHealthandnow Despite beingeffectivesinceJune2007, theunderstandingandimportanceofIHRforhealth-non- P national partnerships for effective alert and response systems. Coordination of nationwide resources, resources, nationwide of Coordination systems. response and alert effective for partnerships national including the sustainable functioning of a National IHR Focal Point (NFP), which is a national centre for IHR IHR for centre national a is which (NFP), Point Focal IHR National a of functioning sustainable the including (2005) communications, is a key requisite for IHR (2005) implementation. The NFP should be accessible accessible be should NFP The implementation. (2005) IHR for requisite key a is communications, (2005) at all times to communicate with the WHO IHR Regional Contact Points and with all relevant sectors sectors relevant all with and Points Contact Regional IHR WHO the with communicate to times all at and other stakeholders in the country. States Parties should provide WHO with contact details of NFPs, NFPs, of details contact with WHO provide should Parties States country. the in stakeholders other and continuously update and annually confirm them. confirm annually and update continuously .2.1 arget akistan levelofcapabilities – – A functionalmechanismis establishedforthecoordination andintegration ofrelevant – – areas and national authorities and assets. national level. The simulation scenarios may also include testing of linkages provinces/ between with clear terms of reference, tested at least yearly through simulation modalities as they are at IHR FPs must also available be 24/7. Provincial task forces should also meet on a regular basis complementedbe with multisectoral IHR Task Forces/committees in all provinces/areas. Provincial Replicating federal IHR NFP and IHR Task Force modalities, IHR provincial focal points (FPs) should multisectoral response to major public health risks that may confront Pakistan. withsupported clear terms of reference tested through periodic table top exercises simulating for communication on IHR/GHSA updates. These should supplemented be and with advocacy of the nationalThe effectiveness IHR Task Force may improved be by holding regular meetings • • • • • documentation Relevant • • • • • strengthening/challenges need that reas A practices trengths/best S concern isinplaceandparticipatedthelatestevent. IHR requirementsonsurveillanceandresponseforpublichealthemergenciesofnationalinternational Score 3: Developedcapacity. A multisectoral, multidisciplinarybody, committeeortaskforceaddressing PoE 2014. Assessment Report IHR 2013. Capacity Assessment Report PakistanDraft Public Health 2010. Act FPs. IHR provincial Provincial notificationsfrom Punjab,Khyber Pakhtunkhwa (KP), Balochistan and Sindh designating Federal notifications designating IHR NFP and establishing the IHR Task Force. IHR structures. Yearly simulations should take place to test and improve the functioning of IHR FPs and multisectoral IHR FPs need to designated be in all provinces/areas with 24/7 communication capacities. clear terms of reference and delineated mutual for benefits all at federal and provincial/area levels. institutionalized and sustainable, multisectoral coordination and collaboration structures based on Strong additional is to needed across highlight advocacy sectors IHR significance and the need for areas. technical The composition of IHR Task Force should reviewedbe to include additional to cover sectors the 19 IHR. of The IHR NFP needs to have alegal mandate to coordinate with non-health for implementation sectors – – – – – – – – – – – – A substantial legal framework for exists almost all IHR core capacities. response). and preparedness basisThe multisectoral hoc/needs (e.g. IHR Task for Zika Force regularly meets and on ad adapted to the provincial context in the post-devolution scenario. PakistanThe draft Public Health developed Act, through aconsultative process in 2010, may be A multisectoral IHR Task Force is established at national level with clear terms of reference. IHR FPs are available in all four provinces. IHR NFPAn is designated at the National Institute of Health (NIH) with 24/7 availability. 13 of IHR Core Capacities of the Islamic Republic of Pakistan PREVENT 14 PREVENT

Joint External Evaluation Support work being coordinated by WHO, FAO, and OIE to develop an integrated and global package of of package global and integrated an develop to OIE and FAO, WHO, by coordinated being work Support security, andnationalsecurity. in humans. This situationthreatenspatientcare, economicgrowth, publichealth, agriculture, economic alarming rate andisoutpacingthedevelopmentofnewcountermeasurescapablethwarting infections Over thepastdecade, however, thisproblemhasbecomeacrisis. The evolution AMR isoccurringatan of resistancewas slowandthepharmaceuticalindustrycontinuedtocreatenewantibiotics. resist being killed by antimicrobial agents. For many decades, the problem was manageable as the growth Bacteria andothermicrobesevolveinresponsetotheirenvironmentinevitablydevelopmechanisms Introduction resistanceAntimicrobial Recommendations for priority actions Recommendations for priorityactions experts, infectiousdiseasespecialistsandmedicalmicrobiologists. certain tertiarycareanduniversityhospitals. There isanationwideshortageofqualifiedinfectioncontrol Programmes for antimicrobial stewardship, surveillance, prevention and control of HCAI are limited to concept ofhealthcare-associatedinfection(HCAI)prevention andcontrolisrelativelynewtoPakistan. need tostandardizelaboratory methods andinterpretationmetricsforantimicrobialresistancetesting. The detection andsurveillanceareintheimplementationstage inatleasttwoprovinces. There isanurgent operational andtacticalresponse formitigationandcontrol. Sentinelsitesforantimicrobialresistance capable ofgenerating qualitydata forevidence-informednationalpolicies, strategies andplans, andtimely surveillance exist, additionalworkisrequiredtodevelopanational AMR detectionand surveillancesystem a national AMR surveillancesystem. Despitethefactthatmanyofcomponents neededfor AMR There isahighlevelofcommitmentandwillingnessatthenationalprovinciallevelsforestablishing the processofdevelopinganational AMR policy. AMR SurveillanceSystem. Subsequently, anintersectoral coresteeringcommitteewas formedtooversee of NHSR&Cteamvisitedselectedsitesinthecountryandmappedavailable capacities for establishingan Global Antimicrobial ResistanceSurveillanceSystem(GLASS). InNovember2015, ajoint WHO/Ministry its population. The MinistryofNHSR&Cexpressedaninteresttojointheearlyimplementation ofthe The GovernmentofPakistan hasrecognized AMR asamajorthreattothehealth anddevelopmentof P T activities to combat antimicrobial resistance, spanning human, animal, agricultural, food and environmental environmental and food agricultural, animal, human, spanning resistance, antimicrobial combat to activities aspects (i.e. a one-health approach), including: a) Each country has its own national comprehensive plan plan comprehensive national own its has country Each a) including: approach), one-health a (i.e. aspects to combat antimicrobial resistance; b) Strengthen surveillance and laboratory capacity at the national and and national the at capacity laboratory and surveillance Strengthen b) resistance; antimicrobial combat to international level following agreed international standards developed in the framework of the Global Global the of framework the in developed standards international agreed following level international Action Plan, considering existing standards and; c) Improved conservation of existing treatments and and treatments existing of conservation Improved c) and; standards existing considering Plan, Action collaboration to support the sustainable development of new antibiotics, alternative treatments, preventive preventive treatments, alternative antibiotics, new of development sustainable the support to collaboration measures and rapid, point-of-care diagnostics, including systems to preserve new antibiotics. new preserve to systems including diagnostics, point-of-care rapid, and measures arget akistan levelofcapabilities – – Global Action Plan for influenza vaccines (GAP). Develop aNational Action Plan to address detection AMR and surveillance in line with the WHO

been approved. Score 1: P trengths/best practices trengths/best S strengthening/challenges need that reas A practices trengths/best S approved. Score 1: Nocapacity. Nonationalplanfordetectionandreportingofpriority AMR pathogenshasbeen P Indicators andscores .3.2 Surveillanceofinfectionscausedby .3.1 – – – – – – – – – – – – – – Antimicrobial resistance detection. – – – – – – – – – – – – – – of provincial and federal laboratories. federal and provincial of surveillance AMR An system for Mycobacterium tuberculosis in exists Pakistan through anetwork HCAI. seminars, and sharing protocols and educational material for antimicrobial testing and control of mostly from the private sector. This helps network create awareness through meetings and involved in surveillance AMR and information patterns on AMR is shared by some laboratories, The Pakistan Antimicrobial Resistance (PARN) Network is anongovernmental organization (NGO) non- health to address sectors the issue ofin AMR Pakistan. There is need for an integrated One Health approach and coordination the health between and methodsLaboratory and interpretation metrics for testing AMR needs to standardized. be strengthened. Infrastructure of diagnostic laboratories in public health and animal health should sectors be A National Action Plan to address needs AMR to developed be in line with the GAP. WHO purposes. Some animal health laboratories are undertaking antibiotic sensitivity testing for treatment Programme. care hospitals, such as multi drug resistance testing under the National Tuberculosis Control Facilities are available for testing some pathogens priority especially at universities and tertiary Resistance. Antimicrobial of Containment for Policy The Ministry of NHSR&C has initiated aconsultative process for the development of aNational the NIH and the Regional WHO for the Eastern Office Mediterranean. publicthe and private health sector. designated The laboratories are workingin collaboration with assessment AMR An mission conducted in 2015 evaluated and designated sentinel sites in both Recently, the NIH was designated as the focal AMR point at the federal level. standardize the antibiotic sensitivity testing and interpretation. and testing sensitivity antibiotic the standardize Strengthen infrastructure of diagnostic laboratories in public health and animal health and sectors animal sectors. and human involves that programme stewardship antimicrobial national a Develop Develop anational programme to address the prevention and control of HCAI. No capacity. No nationalplanforsurveillanceofinfectionscausedby prioritypathogenshas AMR pathogens. 15 of IHR Core Capacities of the Islamic Republic of Pakistan PREVENT 16 PREVENT

Joint External Evaluation P Score 1: Nocapacity. NonationalplanforanHCAIprogramme hasbeenapproved. P Score 1: NoCapacity. Nonationalplanexistsforantimicrobialstewardship activities. trengths/best practices trengths/best S strengthening/challenges need that reas A Relevant documentation Relevant strengthening/challenges need that reas A practices trengths/best S strengthening/challenges need that reas A .3.4 .3.3 Healthcare-associated infectionprevention andcontrol programmes. – – – – – – – – – – – – – – – Antimicrobial stewardship activities. – – – – – – – – – – – – – – – AMR containmentAMR F.No.8-30/2015-DDP-I. policy Formation notification steeringof a committee to oversee the process of developing a national Hospital Waste Management Rules, Notification S.R.O.1013 (1), 2005. 2015. November 23–28 Pakistan, on CountryReport Capacity Review Mission for Early Implementation ofSurveillance AMR in sectors. animal and human in The Government needs to revise and issue regulations to monitor and control the use of antibiotics andAdvocacy knowledge dissemination is needed. providers. health-care low, among generally is even stewardship antimicrobial of Awareness promoters. Antimicrobial peptides are being introduced to replace antibiotics used currently as animal growth policy. Antimicrobial stewardship will an be integral of the planned part national containment AMR Some hospitals, especially in the private sector, practise antimicrobial stewardship activities. programmes. control and prevention infection hospital-based of establishment There is anational need for trained infection control/infectious disease professionals to enable the levels. provincial A comprehensive prevention HCAI and control mechanism is needed both at the federal and these rules are under way in one province. since 2005 and practised in some health-care facilities. Attempts to scale up the applications of A federal government document on Rules of Hospital Waste Management has been available care facilities. health- available are some at units isolation diseases Infectious microbiologists. physicians and Some large care hospitals tertiary have assigned infection prevention and control activities to surveillance. AMR launching nationwide The Pakistan Antimicrobial Resistance should Network empowered be and scaled up to enable system. surveillance AMR Building human capacities and securing laboratory supplies are prerequisites to have afunctional universities. However, capacities and to share report perform, testing AMR are not widely available. Basic laboratory infrastructure in exists many care hospitals, tertiary research institutes and Adopted measured behaviours, policies and/or practices that minimize the transmission of zoonotic zoonotic of transmission the minimize that practices and/or policies behaviours, measured Adopted Recommendations for priority actions Recommendations forpriorityactions necessary legalinstrumentsandmechanisms. However, aOneHealth approach forzoonotic disease management would beboostedbyimplementing surveillance andresponseforotherzoonoticdiseasesofimportance. and between the provinces and the national level. This programme can provide an excellent platform for on ad hoc basis. Coordinationexiststhroughout thesystem, i.e. withintheprovinces, atthenationallevel, jointly investigatedbysamplingbothpopulations, conductinglaboratory diagnostics, andsharingresults in theirrespectivepopulationsofinterestaswellwildbirds. When azoonotic eventissuspected, itis approach. Animal healthandpublicauthoritiesconductroutinesurveillancefor influenzaviruses Asia. This successfulprogramme remainssustainableand ineffectandfollowsanexemplaryOneHealth and Preventionof Avian Influenza was establishedin2006 inresponsetotheemergenceof A(H5N1)in laboratories on both the animal and public health side. Pakistan’s National Programme for the Control diseases includingzoonoticdiseases. Inaddition, thereisacoreoftrained professionals andcapable In response, Pakistan hasestablishedseveral surveillanceprogrammes andprojectstomonitoranimal pandemic Influenza, andanthrax arepriorityzoonoticdiseasesin Pakistan. human–animal interface. Leishmaniasis, rabies, brucellosis, Crimean-Congo haemorrhagicfever(CCHF), important veterinaryhealthpriority. Several zoonoticdiseasesendangerpublichealth, especiallyatthe animal populationisapotentialsourceofzoonoticdiseasesandconsequently, animaldiseasesarean Agriculture andlivestockproductionareimportantcontributorstotheeconomyofPakistan. The large P T human pathogensarezoonotic. recently emerginginfectious diseases affecting humans isofanimalorigin; approximately 60%ofall insect orinanimatevectormaynotbeneededtotransfer themicrobe. Approximately 75%of These diseasesarecausedbybacteria, viruses, parasites, andfungithatarecarriedbyanimals, andan Zoonotic diseasesarecommunicableandmicrobesspreadingbetweenanimalshumans. Introduction Zoonotic diseases diseases from animals into human populations. human into animals from diseases arget akistan levelofcapabilities – – – – – – using aOne Health approach and enhancing laboratory capacity. Enhance training of veterinary and public health professionals on zoonotic disease management zoonotic diseases. priority Conduct systematic surveillance at the human–animal interface using aOne Health approach for One Health approach for zoonotic disease management. Develop and implement legal necessary instruments and coordination mechanisms to adopt a 17 of IHR Core Capacities of the Islamic Republic of Pakistan PREVENT 18 PREVENT

Joint External Evaluation system, butatlessthanhalfofsubnationallevels. Score 3: Developedcapacity. Animalhealthworkforcecapacityexistswithinthenational publichealth P trengths/best practices trengths/best S pathogens ofgreatestpublichealthconcern(variability existsbetweenprovinces). Score 3: Developedcapacity. Zoonoticsurveillancesystemsareinplacefor1–4zoonoticdiseases/ P Indicators andscores trengths/best practices trengths/best S strengthening/challenges need that reas A .4.2 Veterinary oranimalhealthworkforce. .4.1 Surveillancesystemsinplaceforpriorityzoonoticdiseases/pathogens. – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – Training (FELTP) 2-year programme. Programme the veterinariansin include Training programmes of the Health Academy Services and the Field Epidemiology and Laboratory and medical schools. Post-graduate degree programmes in microbiology and epidemiology are by offered veterinary graduates. Medicine Veterinary The veterinary curriculum contains sufficient training for handling zoonotic diseases of Doctor for among livestock, should added be to the list. zoonotic disease burden in Pakistan. Among others, Mycobacterium bovis, which common is very The list of zoonotic priority diseases should reviewed be and updated periodically due to the high levels. district and provincial, should capacity Laboratory also enhanced be tosurveillance support activities at national, levels. provincial national at and interventions related enforcement and The establishment of legal instruments would enhance zoonotic disease surveillance, response, national at provincial stakeholders and levels.the Mechanisms of joint actionneed to developed be and implemented against major zoonoses by all mechanisms. One Health hubs should established be with defined terms of reference and operational Local veterinary vaccine production capability with to exists the tailor capacity to local needs. diseases in the provinces, with plans for expansion. are availableSurveillance capacity for andmonitoring laboratory zoonotic and other animal which coordinates with the livestock department as and when required. movement of animals. The Director General of Health is Services the focal point for the Task Force, A CCHF Task Force has been notified in Balochistan provincewhich has significant cross-border activities. surveillance Some international financial and technical assistance stillis availableOne Healthto support Other One Health have projects been handled jointly in recent years (CCHF, brucellosis). (avian Influenza).system hasThe country past experience of successfully running aOne Health zoonotic disease surveillance A list of zoonotic priority diseases is available. human, animalandwildlifesectorsisestablished. Score 2: Limitedcapacity. Amechanismforcoordinatedresponsetooutbreaksofzoonoticdiseasesby functional. P Relevant documentation Relevant strengthening/challenges need that reas A practices trengths/best S strengthening/challenges need that reas A .4.3 Mechanismsforresponding tozoonosesandpotentialare establishedand – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – World Organisation for Animal Health Performance of Veterinary 2015. Services Notification of establishment of National Zoonoses Surveillance and Research Unit (NaZSRU). Agreement. Health Council Research One Agricultural NIH/Pakistan Pakistan. Plan for Contingency Avian Influenza levels. provincial and national both legal bysupported the necessary instruments that clearly define the role of allstakeholders at A One Health zoonotic disease management programme should developed be and implemented, diseases. zoonotic relevant on focused programme management vector integrated an has also KP KP. in informalAn committee for coordination animal between and public health is established sectors Very strong public–private interaction sector has been built up in the area zoonoses. of poultry A system to exists mobilize field to vets investigate or respond to an outbreak hours. within 24–48 Trained epidemiologists and are laboratory available staff in both public and animal health. expand mechanisms. Experience gained from the avian influenza programmecanbe used as a platform to develop/ this subject. The number of veterinary epidemiologists needs to increased; be FELTP should include training in levels. provincial and national should madeEfforts be to develop training curricula that focus on the One Health approach at for different cadres of public health and animal health professionals at all levels. and in-service Short refresher training modules on zoonotic disease surveillance would useful be international bodies. UVAS has astrong research focus with collaboration with local government, industry, and Health. Public and One Health in the curriculum anand Master offers of Philosophy degree (MPhil) in Epidemiology The University of Veterinary and Animal Sciences (UVAS) in Lahore, Punjab incorporates training on 19 of IHR Core Capacities of the Islamic Republic of Pakistan PREVENT 20 PREVENT

Joint External Evaluation State Parties should have surveillance and response capacity for food and waterborne diseases’ risk or or risk diseases’ waterborne and food for capacity response and surveillance have should Parties State prevention ofhumancases(orfurthercases)needtobeputinplace. the sourceofanevent, basedonariskassessment, suitableriskmanagementoptionsthatensurethe throughout thefoodchaincontinuummustbedeveloped. Ifepidemiologicalanalysisidentifiesfoodas outbreak anditscontainmentiscriticalforcontrol. Riskmanagementcapacitywithregardtocontrol likelihood ofinternationalincidentsinvolvingcontaminatedfood. The identificationofthesourcean developed countries. The rapid globalizationoffoodproductionandtrade hasincreasedthepotential Food andwaterborne diarrhoealdiseasesareleadingcausesofillnessanddeath, particularlyinless Introduction Food safety Centre (NARC), Islamabad –houses19researchinstituteswith96laboratories invarious subsectorsof with sevencentresdistributed throughoutthecountry. Oneofthese–theNational Agricultural Research Research isresponsiblefor research andtechnologysupport. This Councilhasastronginfrastructure In theagriculturesector, thePakistan Agricultural ResearchCouncil oftheMinistryFood Securityand National Animal andPlantHealth InspectionService(NAPHIS), whenandifitisestablished. Codex contactpointiswiththeMinistryofFood Security andResearchisenvisagetocomeunderthe information inrelationtoInternationalFood Safety Authorities Network(INFOSAN)activities. The National in termsofarapid alertsystem forfoodandfeedasisthecaseinEuropeanUnion. There was alsono not wellestablished. There isnoevidentsystemforriskcommunicationoffoodsafety-relatedemergencies However, forchemicalfoodbornediseasesurveillance, linkageswithanimalandagriculture departmentsare institutes inthepublicandprivate sector. This coordinationhasrecentlybeensignificantlystrengthened. Zoonotic diseasesituationsareaddressedincoordination withthelivestockdepartmentsandveterinary Foodborne diseaseoutbreaksareaddressedbythedepartments ofhealthatprovincial/arealevels. Research, butexport-relatedissuesarehandledbytheMinistryofPorts andShippingatthefederal level. of theimportfishandfisheryproductsisresponsibilityMinistryNational FoodSecurityand responsibilities ofthe Agriculture, LivestockandDairyDepartmentsattheprovincial level. Qualitycontrol authority/mechanism toenforceuniformity. Crop andanimalhealthsafety, includingzoonoses, are covered infoodlegislation. Eachprovinceseparately dealswiththesubjectandthere isnofederal level address thepreventiveapproachtocompletefoodchain. Neitherarerisk-basedpreventiveapproaches Where present, legislationgenerally coversonlyanendproductinspectionandtesting anddoesnot Baltistan (GB)donothaveafoodact; ICTimplementsthePureFood Ordinanceof1960). to establish the Food Authority. However, this is not the case in all provinces and territories (AJK and Gilgit- Food Act andRegulations. ProvincessuchasPunjabandKPhavepassedaFood Act andalsohavean Act Food and Agriculture Department(KP)orFood Authority (Punjab, KP)etc. isresponsibleforenactingthe agriculture andhealthsectorweredevolvedtotheprovinciallevelin2011. At thislevel, anentitycalleda the provinciallevel. With the 18th Amendment to the Constitution of Pakistan, most functions ofthe Food safetyisaresponsibilityofmultipleministriesatthefederal levelanddepartments ofhealthat P T events. It requires effective communication and collaboration among the sectors responsible for food safety safety food for responsible sectors the among collaboration and communication effective requires It events. and safe water and sanitation. and water safe and arget akistan levelofcapabilities Recommendations for priority actions Recommendations forpriorityactions outbreaks isfragmented, varying acrossprovinces. varying safetylevels. Inaddition, theresponsecapacityforfoodborneemergencies, incidentsanddisease This impliesthatfoodstraded interprovinciallyandgloballyareunderdifferentlevels ofcontroland disease surveillanceandriskcommunication. There islimitedcoordinationcurrently fromthefederal level. in termsoflegislation, standards, foodcontrolmanagement, inspectionandenforcement, foodborne One ofthemainpost-devolutionchallengesisthateachprovincehandlesfoodsafetyinadifferentmanner levels. proposed tohaveastrongcollaboration functionwiththeMinistryofNHSR&Catnational andprovincial oversee thatfoodsafetycontrolmanagementisimplementeduniformlyacrosstheprovinces. Itisalso and developmentofstandards, wouldbeexpectedtodevelopprotocolsandproceduresgenerally and PlantHealthInspectionService. This body, ifestablished, inadditiontocontrolsforimportsandexports There isabilltoestablishregulatorybodyforfoodsafety, animalandplanthealth–theNational Animal Pakistan Agricultural ResearchCouncil, andaLivestockDairyDepartment)Board. this Ministryincludean Animal Quarantine Department, Livestock Wing, National Veterinary Laboratory, international liaisonandeconomicstudiesforframing agriculturepolicies. Someoftheimportantarms formulation, economiccoordinationandplanninginrespectoffoodgrains andagriculture. Italsocovers National Food Security&Researchwas establishedatthenationallevelwithresponsibilityforpolicy regard toestablishingnation-widestandards, importsand exports andaregulatory body. The Ministryof A decisionwas taken tobringbacksomefunctionsoffoodcontrolthefederal level, particularlyin Fisheries. and provinciallevelsorintersectorally betweentheministriesofHealthand Agriculture, Livestockand across thefoodchain(primaryproductiontoconsumption)isgenerally notwelladdressedwithinfederal the capacityforfoodsafetytestingislimited. The overall coordinationforfoodsafetycontrolmanagement The laboratory set-up for food safety controls is at the NIH at federal level. Some provinces have labs but food controlmanagementactivities. diseases, coveringavianinfluenza. This providesagricultural supportbutisthusfarnotwellutilizedfor In addition, twoofthelabsareaccredited, oneintheareaofgrain testingandtheotherforpoultry agriculture. These laboratories generally havecapacitytotestforresidues, contaminantsandheavymetals. – – – – – – – – – – Develop asystem for risk assessments, ideally at the federal level. levels. area federating and provincial Improve understanding and interpretation of laws for coordination better the federal, between implementation laws. of food safety better for areas federating and provinces across processes and procedures of uniformity Improve traceability and recall, and links with research. including sharing of data, a rapid system alert for food and feed, emergencies, food safety Develop and document aformal mechanism for cross-sectoral collaboration and coordination, outcomes. safety Develop anational strategy food safety and using policy risk-based approaches to achieve food 21 of IHR Core Capacities of the Islamic Republic of Pakistan PREVENT 22 PREVENT

Joint External Evaluation authority isestablished, manyofthefunctionsshouldbecoveredgradually overaperiodoftime. for foodbornediseaseandfoodcontamination. IntheMinistryof Agriculture, oncethenewregulatory provinces butcertain(e.g. ICTandPunjab)haveabettersurveillanceresponsecapacity animal healthsectors, surveillanceandresponsestaff, key laboratories). This wouldgenerally applyacross trengths/best practices trengths/best S Score 2: disease andfoodcontamination. P Indicators andscores Relevant documentation Relevant strengthening/challenges need that reas A .5.1 Mechanismsare establishedandfunctioningfordetectingresponding tofoodborne – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – Limited capacity. Pakistan Standards and Quality Control Act, 1996. Act, Control Quality and Standards Pakistan 1976. Act, Restaurant and Hotels Pakistan 2014. AuthorityAct, Safety Food KP Multi Nutrition Sector Strategy Punjab, 2014 Punjab 2011. AuthorityAct, Food Ordinance, 2013. Government Punjab Local Ordinance, 2015.Punjab Food Ordinance, 1968. Punjab Food Pure Ordinance, 1960. Food Pure Research organizations should controls tappedfor be food safety and decision-making. based decision-making, should strengthened. be The system for the collation and sharing of data from different agencies, and their use for evidence- More consistency is needed among provinces in terms control of food safety management. outcomes, with aview to cover across food safety the food chain. Better linkage should sought the be health between and agriculture to achieve sectors food safety safety. food domestic for oversight and import; and export for controls and implementation has been proposed to established, be which would coordinate functions of standards; their A new regulatory authority (the National Animal and Plant Health Inspection [NAPHIS]) Service A risk-based approach must included be in the development of standards and their implementation. Coordination standards of food safety across the is country lacking Research Council needs to utilized. more be effectively researchThe good available capacity within the various centres of the Pakistan Agricultural related emergencies. investigate foodborne outbreaks with multisector collaboration for rapid response to food safety- There is an established mechanism under which health authorities at provincial and district levels provinces is lacking. between standards however, safety levels of equal governments; provincial of coordination The responsibility for enacting and implementing and Regulations Act the Safety Food lies with Focal pointsareidentifiedinrelevant domains(foodsafety, humanhealth, and A whole-of-government national biosafety and biosecurity system is in place, ensuring that especially especially that ensuring place, in is system biosecurity and biosafety national whole-of-government A Recommendations for priority actions Recommendations forpriorityactions This internationalcommitmentisanessentialelement of theendgameforglobalpolioeradication. materials withtheobjectivetodestroyorsafelycontainallstocksofwildandvaccine-derived polioviruses. conducting a nationwide survey to identify facilities that might store stocks of polioviruses or infectious access. Together withallcountriesinthe WHO Eastern Mediterranean Region, Pakistan iscommittedto Laboratory for Poultry Disease (NRLPD) have an accredited facility with biocontainment and controlled that couldmaintainandcontrolbiohazardmaterials. Somelaboratories suchasthe NationalReference inventory ofbiohazards, althoughapatchynetworkexistsofpublichealthand/orveterinarylaboratories guidelines andrules. Legislationexistsonbiosafetybutismissingforbiosecurity. There isnosystematic Pakistan hastaken initialstepstowards reachingthetargetsforbiosafetywithdrafting ofsomenational P T the environment. infectious agentsagainstthosewhowoulddeliberately misusethemtoharmpeople, animals, plants, or and biosecuritytoprotectresearchersthecommunity. Biosecurityisimportantinordertosecure to workwithinfectiousagentshaveraised concernsregardingtheneedtoensureproperbiosafety natural anddeliberate origin. At thesametime, theexpansionofinfrastructure andresourcesdedicated tools thatareneededtodetect, diagnose, recognize, andrespondtooutbreaksofinfectiousdiseaseboth Research withinfectiousagentsiscriticalforthedevelopmentandavailability ofpublichealthandmedical infectious diseases. robust setoftools—suchasdrugs, diagnostics, andvaccines—to countertheever-evolving threatof Working withpathogensinthelaboratory isvitaltoensureingthattheglobalcommunitypossessesa Introduction biosecurity and Biosafety dangerous pathogens are identified, held, secured and monitored in a minimal number of facilities facilities of number minimal a in monitored and secured held, identified, are pathogens dangerous according to best practices; biological risk management training and educational outreach are conducted conducted are outreach educational and training management risk biological practices; best to according to promote a shared culture of responsibility, reduce dual use risks, mitigate biological proliferation and and proliferation biological mitigate risks, use dual reduce responsibility, of culture shared a promote to deliberate use threats, and ensure safe transfer of biological agents; and country-specific biosafety and and biosafety country-specific and agents; biological of transfer safe ensure and threats, use deliberate biosecurity legislation, laboratory licensing, and pathogen control measures are in place as appropriate. as place in are measures control pathogen and licensing, laboratory legislation, biosecurity arget akistan levelofcapabilities – – – – – – – – Carry out risk-basedCarry training staff on biosecurity procedures and their assessment. establish such adatabase. toof polioviruses identify stocks and infectious materials will provide an excellent to opportunity identification of collected pathogens and toxins.The nationwide thatsurvey Pakistanwill conduct Establish an updated database of facilities housing dangerous pathogens and toxins, including country. the regulationsin legislation and/or biosafety/biosecurity strengthen and Implement allocation. and identification resource including Federal and provincial authorities to develop acomprehensive biosafety/biosecurity programme, 23 of IHR Core Capacities of the Islamic Republic of Pakistan PREVENT 24 PREVENT

Joint External Evaluation pathogens andtoxins. have sustainedacademictraining ininstitutionsthattrain personnelwhomaintainorworkwithdangerous biosafety andbiosecuritybest practices forsafe, secure and responsible conduct. The country does not yet training curriculum. Awareness isgenerally lackingamong the laboratory workforceoninternational in biosafetyandbiosecuritytraining, buthasnotyetimplementedcomprehensivetraining oracommon Score 2: Limited capacity.Pakistan hasconductedatraining needsassessmentandidentifiedgaps P are inplace. Pakistan isdeveloping: enforcement mechanisms. However, someelementsofacomprehensivebiosafetyandbiosecuritysystem use ofdiagnosticsthatprecludeculturingdangerouspathogens; andlimitedoversight, monitoringand inadequate consolidationofdangerouspathogensandtoxins atalimitednumberoffacilities; limited monitoring ofpathogenswithinafacilityislackingandoversightenforcementadhoc. There is Score 2: Limitedcapacity. This scorewas givenacknowledgingthataprocessfortheinventoryand and agriculture facilities. P Indicators andscores trengths/best practices trengths/best S strengthening/challenges need that reas A practices trengths/best S .6.2 Biosafetyandbiosecuritytraining andpractices. .6.1 Whole-of-government biosafetyandbiosecuritysystemisinplaceforhuman, animal, – – – – – – – – – – – – – – – – – – – – – – – – – – – – handling and failure systems. reporting pathogen control measures, including standards for physical containment and operational licensing; laboratory legislation; biosecurity and national biosafety comprehensive that store or process dangerous pathogens and toxins; a process to establish and monitor an updated record and inventory of pathogens within facilities Some accredited laboratories use international practices. best There is afunctional biosafety level (BSL)-3 laboratory at the national level. Biosafety personnel are trained at academic and international organizations. strengthened. materials be biohazardous should of nationalThe capacity and provincial laboratories to house, manipulate and safely destroy A system is needed for the inventory and monitoring of dangerous pathogens. country. whole the to extended be regulationsshould legislation and/or biosecurity of Implementation ProvincialKP Reference follows Laboratory national guidelines for tuberculosis (TB) control. Pathogens under appropriate are transported conditions. through undertaken an ongoing NIH. process Trained are biosafety officers placed somein laboratories at national and provincial levels.This is and do notobjects cover naturally occurring infectious agents). Pakistan Biosafety Rules were notified in 2005 (although they only regulate genetically modified Relevant documentation Relevant strengthening/challenges need that reas A – – – – – – – – – – – – – – – – Draft NationalDraft Biosafety Policy. Code of Conduct for Life Scientists, 2009. 2005. Guidelines, Biosafety National Pakistan Rules, Biosafety 2005. dangerous or infectious materials. Personal protective equipment (PPE) must provided be to working all with staff potentially Funding are and capacity needed to sustain biosafety and biosecurity training. and assessment exercises. Regular assessments are required for biosafety and biosecurity needs as well as regular monitoring Comprehensive biosafety and biosecurity rules need to adopted. be 25 of IHR Core Capacities of the Islamic Republic of Pakistan PREVENT 26 PREVENT

Joint External Evaluation A functioning national vaccine delivery system—with nationwide reach, effective distributions, access for for access distributions, effective reach, nationwide system—with delivery vaccine national functioning A T deaths ayearglobally. ways to save lives and prevent disease. Immunizations are estimated to prevent more than two million Immunization isoneofthemostsuccessfulglobalhealthinterventionsandcost-effective Introduction Immunization innovative approachessuchasandroidhand-helddevices forreal-timemonitoringofvaccination. The resource managementandcapacity; implementingmeaslessurveillancewithlaboratory confirmation; and including monitoringandevidence-based correctiveactionsandaccountability; improvements inhuman The GovernmentofPunjab hastaken several strongmeasures toimproveroutineimmunizationcoverage, with appropriateperformance-based, indicator-linked reimbursement. federal andprovincialmechanisms tofinanceEPIthroughestablishmentoftheMulti-Donor Trust Fund during thelast12months. Mostcritically, agreementhasbeenreachedwithprovincesanddonors on a Vaccine LogisticsManagementInformationSystem(VLMIS)have resultedinnostockouts inanydistrict critical function. Implementationofeffectivevaccine managementacrossthecountryandintroductionof for pooledvaccine procurement bythefederal EPIhasovercomethelongstandingconfusionaroundthis made several criticaladvancements withinputsandconsentofprovinces. The agreement andprocesses Emerging frompost-devolutionchallengesaffectingthe immunization programme, thefederal EPICellhas vaccination staffornofacilities thatprovidevaccination. of union councils (and health facilities) in theprovinces of Sindh, Balochistan and KP eitherhave no of rigorous monitoring and surveillance systems linked to robust accountability. A significantproportion challenges relatetoinadequacyofinfrastructure todelivervaccines, insufficienthumanresources, andlack While thereareseveral rootcausesoflowimmunizationcoverage, themostpervasive andrecalcitrant measles dosecoverage assessedat61%in2012isalsoestimatedtohaveincreased 68%in2015. by theprogramme in2015tohaveincreased63%(range: 30%Baluchistan–67%Punjab). The first children 12–23monthsofagewas 54%(range: 16%Baluchistan –66%Punjab). This was estimated The mostrecentassessedestimate(2012Pakistan Demographic andHealthSurvey) offullyimmunized outbreaks of VPDs, particularlymeaslesandpolio, haveaffectedallprovinces. levels of immunization coverage exist between provinces and between districts in each province. Periodic proportion ofchildrenremainingunprotectedfromvaccine-preventable diseases(VPD). Wide variations in The EPIinPakistan hassufferedfromgapsinimmunizationservicedeliveryresultingasubstantial policy formulationandcoordinationbetweenthefederal andprovincialprogrammes. devolution, which severely disrupted vaccine procurement, financing and donor relations, immunization past 18–24months. The federal EPIinparticularisresurging afteraperiodofnearcollapsefollowing The ExpandedProgramme forImmunization(EPI)inPakistan hasmadesignificant stridesduringthe P marginalized populations, adequate cold chain, and ongoing quality control—that is able to respond to to respond to able is control—that quality ongoing and chain, cold adequate populations, marginalized new disease threats. disease new arget akistan levelofcapabilities trengths/best practices trengths/best S plan isinplacetoreach90%withinthenextfiveyears toincludesupplementalimmunizationactivities. one doseofmeasles-containingvaccine, asdemonstrated bycoverage surveysoradministrative data; a Score 2: Limited capacity.Of thecountry’s 12-month-old population, 50–69%havereceivedatleast P Indicators andscores • Recommendations forpriorityactions outbreaks acrossprovinces. provincial programmes toconductpredictiveanalysesofrisksandmeasurespreventlarge-scalemeasles outbreaks ofmeaslesandother VPDs remainsreal. Technical partnersshouldassistthefederal EPIand Given thelowmeaslesvaccination coverage inthreeofthefourmajorprovinces, theriskoffrequentlarge remains low. the massvaccination campaignsconductedin2014andwhereroutinechildhoodvaccination coverage responding tooutbreaksofmeaslesinareaswherecoverage withmeaslesvaccine was suboptimalduring VLMIS pilotphaseandareintheprocessofrevamping theircoldchaininfrastructure. Sindhiscurrently multiple challengesofreachinghard-to-accesspopulations. All districtsofSindhareparticipatinginthe cold chain)areunderway. KPhasachieved65%coverage withthefirstdoseofmeasles vaccine, despite has beenapproved. MeasurestorestoreEPIinfrastructure (humanresources, servicedeliverylogisticsand Government ofBalochistanhastaken concretestepstodevelopacostedEPIimprovementplanwhich • • .7.1 Vaccine coverage (measles)aspartofnationalprogramme. 2. 1. to: immunizationExpand delivery service and restore logistic and human resource infrastructure in order – – 2. 1. all enable: levels at that management Establish for programme robustsystems monitoring, surveillance, for data VPD and capacity 3. laboratory testing; and using the trained workforce. mobilizing communities with vaccine hesitancy; enhancing the specimen case transport system for planning and ability to vaccinate children in areas that are hard to reach or are insecure; engaging and particular: leveraging and building on monitoring, disease surveillance and data management, micro Systematically adapt the best practices and of assets the polio eradication initiative to EPI, support in 3. – –

establish vaccination centres in health facilities that currently are not providing the service; finance with defined rolesEPI and responsibilities. Agreement with provinces and donors has been reached on federal and provincial mechanisms to partners. A national costed plan has been approved with broad from provinces, support donors and performance accountability and validation of disbursement linked indicators (DLIs); linked indicators validationdisbursement of and accountability performance centres; EPI non-functioning in or vaccinationstaff lack councilsthat union in rehabilitate services and programme planning; programme and Systematic use of data on EPI collected by the polio eradication initiative for corrective actions enhance capabilities for mobile and outreach vaccination. outreach and mobile for enhance capabilities VPDs and preventionVPDs outbreaks. of prompt detection and response to VPD outbreaks, monitoring of the changing epidemiology of 27 of IHR Core Capacities of the Islamic Republic of Pakistan PREVENT 28 PREVENT

Joint External Evaluation stockouts atthecentral levelandonlyrare stockouts atthedistrictlevel. 79% ofthetargetpopulationincountry; functionalvaccine procurementandforecasting leadtono Score 4: Demonstrated capacity. Vaccine delivery(maintainingthecoldchain)isavailable in60– P reas that need strengthening/challenges need that reas A Relevant documentation Relevant strengthening/challenges need that reas A practices trengths/best S .7.2 Nationalvaccineaccessanddelivery. – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – Multiple Indicator Cluster Survey (Unicef, Governments) Provincial Cluster Survey Indicator Multiple 2019-20. Planning Commission Form 1(PC-1) Programme Expanded on Immunization (EPI) 2015-16 to the Islamabad Mandatory Vaccination and Protection of Health Workers 2015 Act, Sind. Timely refurbishment of cold chain infrastructure should especially effected, be in Baluchistan and country. the across systems management vaccine Expansion is needed for full implementation and efficient maintenance VLMISof and effective deliveryservice through both static facilities and mobile outreach. Provincial plans include refurbishment and expansion of the cold chain to optimize vaccination of VLMIS has led to no stockouts in any district over the last 12 months. vaccine Effective management across the has country recently been implement and introduction EPI. National consensus has been reached on the processes to poolvaccine procurement by the federal programmes. Limited for exists data capacity management and analyses in federal EPI and most provincial of Punjab has initiated surveillance case-based for measles and rubella with laboratory diagnosis. No systematic laboratory-linked surveillance for other exists VPDs than polio. Only the province vaccination services. large proportion of union councils are without trained and health staff facilities that canoffer Significant gapsexist in immunization deliveryservice and human and material infrastructure – a broader EPI, as noted above. A range of practices best demonstrated by the polio eradication programme will utilized be for Legislative bills on mandatory immunization are under review in Sind, Punjab and ICT. plan. multi-year Each province has developed acosted EPI improvement plan aligned with the national costed process. financial reimbursement The recently established Multi-Donor Trust Fund has an appropriate performance indicator-based l l l l

Sindh, 2014Sindh, 2014Punjab, 2010 Pakhtunkhwa, Khyber 2010 Balochistan, – – – – – – Immunisation Supply Chain in Pakistan (2015-2018), 2015. Comprehensive Vaccine Effective Management (EVM) Improvement Plan to strengthen the VaccineEffective Management Assessment) Pakistan, (EVM Report 2014. andNIPS ICF International. 2013. Demographic and Health Survey 2012-13. Islamabad, Pakistan, and Calverton, Maryland, USA: National Institute of Population Studies (NIPS) [Pakistan] and ICF International. Pakistan 29 of IHR Core Capacities of the Islamic Republic of Pakistan PREVENT 30 DETECT

Joint External Evaluation Real-time biosurveillance with a national laboratory system and effective modern point-of-care and and point-of-care modern effective and system laboratory national a with biosurveillance Real-time education; andpartnershipscommunication. and specializedtesting; laboratory oversight; emergencyresponse; publichealthresearch; training and food safety including disease prevention, control, and surveillance; integrated data management; reference can serveasafocalpointfornationalsystem, throughtheircorefunctionsforhuman, veterinaryand response, environmentalmonitoring, anddiseasesurveillance. Stateandlocalpublichealthlaboratories Public healthlaboratories provideessentialservicesincludingdiseaseandoutbreakdetection, emergency Introduction National system laboratory DETECT Recommendations for priority actions Recommendations forpriorityactions sector laboratories havenoobligationtoreportdetectedcases. majority ofpatienttestingisperformedintheprivate sector, withlimitedgovernmentalcontrol: private However, therearenolaboratories intheprovinceswithpublichealthresponsibilitiesatthisstageand and otherprivate sectorcareproviders. Control Programme fordetectionandmanagementofcasesthroughits2000+basic management units by thePakistan National Accreditation CounciltoISOstandards. There isapublic–private mixinthe TB laboratories havehighlydevelopedtoolssuchasgenomesequencing. Eightlaboratories areaccredited Mouth DiseaseLaboratory. The transportation ofsamplesforpoliodiagnosisiswellestablished. Some National ReferenceLaboratory forPoultry Disease, NIH, Polio Laboratory, andthe Veterinary Foot and Pakistan hassomelaboratories withexcellentcapabilitiesandcapacityincluding, but notlimitedto, the P T laboratory-based diagnostics. laboratory-based arget akistan levelofcapabilities – – – – – – – – linking with federal reference laboratories. reference federal with linking Introduce external quality assurance schemes (EQAS) at all levels at starting provincial level and Develop acoordination mechanism for sharing zoonoses diagnosis and research capabilities. health laboratories and establish four provincial public health reference laboratories in country. the Strengthen infrastructure and human resources for diagnostic, food, public health and animal standards. Approve and implement the National Policy, Laboratory in particular the establishment of minimum testing strategies aredocumented. Structureduseofpoint-of-care testingisnotestablished. Score 2: Limitedcapacity. Minimal laboratory diagnostic capability exists, but no tier-specific diagnostic D.1.3 Effectivemodernpoint-of-care andlaboratory baseddiagnostics. system isatdemonstrated capacity4). advanced diagnosticsfrom50–80%ofintermediatelevel/districts(TBandpoliosample transportation Score 3: Developedcapacity. Asystemisinplacetotransport specimenstonationallaboratories for D.1.2 Specimenreferral andtransport system. trengths/best practices trengths/best S strengthening/challenges need that reas A practices trengths/best S strengthening/challenges need that reas A practices trengths/best S 10 coretests. Score 4: Developedcapacity. The nationallaboratory systemiscapableofconducting5ormorethe D.1.1 Laboratory testingfordetectionofprioritydiseases Indicators andscores – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – Systems for the transportation of samples other than and TB polio need to improved. be The specimen shipment to network overseas referral labs is to strengthened. be Domestic regulations for sample transportation need to developed. be national laboratories. A courier system to exists transport specimens from intermediate/district levels to reference and Staff are trained in packing and shipping samples, especially TB, polio and some animal samples. transport. Standard operating procedures (SOPs) are in place for specimen collection, packaging, and The provincial designated labs should upgraded be to undertake the 10 core tests. trainingActive of the workforce should ensured, be and succession for planned. experienced staff labs. mechanismsActive need to set be up at national level for validation of the used tests in provincial utilized at all levels in the country. National diagnostic algorithms for performance of core laboratory should tests developedbe and Research Centre. are the NIH, NARC, Aga Khan University and Shaukat Khanum Memorial Cancer Hospital and Examples in and of international expertise capacity standards in the public and private sectors Collaboration international with exists laboratories forreferral test control. and quality mouth disease diseases. and poultry Disease-specific reference laboratories are established, includingTB, polio, influenza,foot and Procurement is carried out using standard procedures. institutions. A system of reagent and laboratory material procurement in exists almost all public sector 31 of IHR Core Capacities of the Islamic Republic of Pakistan DETECT 32 DETECT

Joint External Evaluation verifying theirimplementation. Score 2: Limitedcapacity. Nationalqualitystandardshavebeendevelopedbutthereisnosystemfor D.1.4 Laboratory qualitysystem. trengths/best practices trengths/best S strengthening/challenges need that reas A Relevant documentation Relevant strengthening/challenges need that reas A – – – – – – – – – – – – – – – – – – – – – – – – – – – – WHO laboratory quality management system handbook. system management quality laboratory WHO laboratories. accredited the from Certificates Disease early warning systems booklet regarding sample selection and shipment protocols. Policy. National of Laboratory Draft The adoption of quality management systems should promoted. be laboratories. food and veterinary the in A nationally coordinated EQAS should established be for all core human and tests relevant testing laboratories. food and allveterinary human, of inspection and The National Policy Laboratory needs to adopted be and implemented to establish the licensing andKP Punjab have laboratory licensing and inspection. Several key laboratories participate in EQAS, such as TB, measles and rubella, and NRLPD. The polio, measles, influenza andTB programmes at NIH areWHO accredited. accredited eight laboratories. ISO accreditation is available through Pakistan National Accreditation Council, which has Training at all of staff levels of testing needs to improved. be Few vendors provide long-term after-sale for services repair and maintenance of equipment. laboratories; of tiers national, or provincial, testing. and community district No developed for structure exists the use of point-of-care and laboratory-based testing in different Strengthened foundational indicator- and event-based surveillance systems that are able to detect events of of events detect to able are that systems surveillance event-based and indicator- foundational Strengthened web-based dashboard-type userinterfacethat hasawiderange ofdescriptive reportingfeaturesbutfewer Sindh). Datafrommultiple sources isenteredandcollectedintoacentral databaseandvisualizedthrougha selected managementinformation systems(maternal, newbornandchildhealth, andlayhealthworkers in operational atthefederal level. This islinked withprovincial districthealthinformationsystems(DHIS)and An electronicdiseaseandhealth indicatorreportingsystemandwebapplicationhasbeen developedandis mainly inthecontextofhighlypathogenicavianinfluenza outbreaks. with thehumanhealthsector, cooperation andcoordinationhasoccurredinthepast, althoughad hoc provincial andfederal levels. Zoonoticdiseasedataconcerninglivestockarecurrentlynotroutinelyshared The latterdataaremainlyusedwithinthelivestocksector andarereportedupwards fromthedistrictto Surveys forprevalence estimation amonglivestockhavealsobeenconductedforsomezoonoticdiseases. herd inspections, wheresamplesarecollectedforscreening purposesorforoutbreakmanagement/control. Animal Health)standards and reportingcriteria), utilizingdatacollectedforclinicaldiagnosisandthrough In thelivestocksector, laboratory-based notificationsystemsexist (basedonOIE(World Organisationfor and analyticalstudies. (except Punjab). With theSUPPORT OFFELTP, thegraduates are abletoperformoutbreakinvestigations at DiseaseSurveillanceandResponseUnitseachprovincialDirectorGeneral ofHealth Serviceoffice these programmes, epidemiologistsarebeingtrained, and graduates workatboththefederal leveland levels, theFELTP atNIHissignificantly strengtheningacompetentepidemiologyworkforce. Through Along withsignificantcontributionsfromotherpublicandprivate institutionsatnational andprovincial based oncasenotificationhavebeendevelopedforthetuberculosisandpolioeradication programmes. capable ofnotifyingandcollectingdefinedcasedatadoexist. Goodpractices for diseasesurveillance not exist. Inthehumansector, thereareexceptionsasseveral enhancedverticalsurveillancesystems based onclinicaldiagnosis)havenotbeenspecified. Disease-specificcasedefinitionsfornotificationdo notifications arenotrequired, andthusstatutorylistingsofnotifiablediseases(laboratory confirmedor case-based surveillancesystemsaremissingfromthehumanhealthsector; physicianand/orlaboratory health sectors. The mainexistinggenericsystemsareevent-andsyndrome-based. Comprehensivegeneric Several infectious disease surveillance systemsoperate in Pakistan, in both the human health and livestock P T biological events. leading anintegrated biosurveillanceeffortthatfacilitatesearlywarning andsituationalawareness of The purposeofreal-timesurveillanceistoadvance thesafety, security, andresilienceofthenationby Real-time surveillance significance for public health, animal health and health security; improved communication and collaboration collaboration and communication improved security; health and health animal health, public for significance across sectors and between subnational, national and international levels of authority regarding surveillance surveillance regarding authority of levels international and national subnational, between and sectors across of events of public health significance; improved country and regional capacity to analyse and link data data link and analyse to capacity regional and country improved significance; health public of events of from and between strengthened, real-time surveillance systems, including interoperable, interconnected interconnected interoperable, including systems, surveillance real-time strengthened, between and from electronic reporting systems. This can include epidemiologic, clinical, laboratory, environmental testing, testing, environmental laboratory, clinical, epidemiologic, include can This systems. reporting electronic product safety and quality, and bioinformatics data; and advancement in fulfilling the core capacity capacity core the fulfilling in advancement and data; bioinformatics and quality, and safety product requirements for surveillance in accordance with the IHR and the OIE standards. OIE the and IHR the with accordance in surveillance for requirements Introduction arget akistan levelofcapabilities 33 of IHR Core Capacities of the Islamic Republic of Pakistan DETECT 34 DETECT

Joint External Evaluation Recommendations for priority actions Recommendations forpriorityactions through theirrespectivemanagementinformationsystems. paralysis (AFP)surveillance, whiledatafromsomeverticaldiseasesurveillancesystemsarechannelled syndromic surveillance areavailable throughdisease early warning systems(DEWS), DHIS andacute flaccid based on operational performance and outcomes and do not relate to infectiousdiseasethreats. Data on Surveillance System(DSS)andDengueDashboard”, arealsooperational. Mostindicatorsare DHIS dashboardsareoperational. InPunjab, dashboardsforcommunicablediseases, namelythe “Disease analytical functions. The dashboardsareavailable atthefederal levelaswellintheprovinceswhere reas that need strengthening/challenges need that reas A practices trengths/best S public healththreats. Score 3: Developedcapacity. IndicatorORevent-basedsurveillancesystem(s)isinplacetodetect D.2.1 Indicatorandevent-basedsurveillancesystems. Indicators andscores – – – – – – – – – – – – – – – – – – – – – – – – – – – – their strengths and practices. best leveraging while programme, surveillance national the with integrated be to programmes Vertical Increased resource allocation is needed (financial and technical). Existing public health labs to strengthened, be extended, and linked with surveillance programmes. A structurednational surveillance programme needs to have an integrated approach. A legal framework for surveillance to formulated be and enacted. at national and provincial levels with government funding and the assistance of FELTP. Provincial Disease Surveillance and Response Units are being established for disease surveillance information. surveillance-related The multiple dashboards available in different provinces and at national level plan to gather based). Vertical programmes such as polio have their own surveillance mechanism (indicator- and event- The DHIS on communicable report diseases. A dashboard is integrated at the Ministry of NHSR&C. fever severe (VHF), acute respiratory infections (SARI), etc. Surveillance is functional and event-based for acute VPDs, diarrhoea, watery viral haemorrhagic surveillance system, replicating and building on current strengths and practices. best Start the process to integrate vertical surveillance systems into awider comprehensive horizontal national, provincial and district levels. sharing human between health, livestock management, and wildlife food safety at sectors Establish permanent cross-sector platforms for surveillance and response cooperation and data modified for implementation in thepost-devolution administrative environment “Act on Pakistan Public Health (Surveillance Response), And 2010” should readdressed be and diseases and indicators AMR (including physician and laboratory notification). legislationThe Draft Formulate and enact infectious disease surveillance and control legislation with alist of notifiable Score 2: Limitedcapacity. Reportsrelatedtodatacollectionaresporadic withdelays. D.2.3 trengths/best practices trengths/best S strengthening/challenges need that reas A practices trengths/best S time reportingsystem, foreitherpublichealthorveterinarysurveillancesystems. Score 2: Limitedcapacity. The countryisdevelopinganinteroperable, interconnected, electronicreal- D.2.2 Interoperable, interconnected, electronic real-time reporting system. – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – Analysis ofsurveillancedata. and definitions case havebeen developed by the vertical programmes. Indicator-based surveillance system(s) and mechanisms, disease, list a and conditions priority of Analysis is available. capacity Short-term training coursestraining and DEWS are provided. Training is also provided for RRTs. A national dashboard exists. android phones exists for selected diseases. electronicAn reporting system in exists all provinces. In Punjab, electronic reporting through Diseases are under surveillance through IDSR in six pilot of districts KP. DSS is available in Punjab. (IDSR). systems response and surveillance SARI, respiratory infections, tract pyrexia of unknown origin, through DHIS and integrated disease AFP surveillance systems exist for Middle East respiratory syndrome coronavirus (MERS-CoV), with special focus on data analysis. FELTP, as well as at other public and private institutions, for fellows from human and animal health laboratory component already of the programme apart (FELTP). Long-term training is offeredat The Field Epidemiology Training Programme is well established in the with and country additional The One Health approach is not comprehensive. Intermediate levels (subregional) are not included/involved in real-time reporting. Public health laboratories (human and animal) to linked be with surveillance. sectors. animal Resource allocation and capacity-building for public health is needed in both the human and communicationIT equipment and tools should enhanced. be platforms. surveillance main into integrated be should data programme Vertical and linked with the national dashboard. Electronic reporting systems should of expandedsurveillance be as part systems in all provinces Web-based reporting is in place for TB. Electronic reporting systems are functioning in Punjab (Dengue Dashboard and DSS Dashboard). Disease-specific reportingsystems exist (polio, influenza). The workforce is trained for surveillance and response (rapid response teams; RRTs). National and provincial (DHIS) dashboards are in place. information. health-related available are capture to platforms information Electronic 35 of IHR Core Capacities of the Islamic Republic of Pakistan DETECT 36 DETECT

Joint External Evaluation core syndromesindicativeofpublichealthemergencies. Score 4: Demonstrated capacity. Syndromicsurveillancesystem(s)inplacetodetectthreeormore D.2.4 Syndromic surveillancesystems. reas that need strengthening/challenges need that reas A Relevant documentation Relevant strengthening/challenges need that reas A practices trengths/best S – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – Pakistan International Health Regulations Report, 2014–2015. Report, Regulations Health International Pakistan Pakistan Public Health (Surveillance Response) And 2010 Act, (Draft) The private should sector included be in the surveillance reporting network. cases. of confirmation on lab based be should Notifications enhanced. be to capacity-building and allocation Resource There is aneed for standardized definitions, case and updated guidelines and mechanisms. Consensus-building should promoted national the disease be on list. priority The disease prioritization mechanism should improved be and updated on aregular basis. A legal framework for real-time surveillance needs to developed be and implemented. Data validation mechanisms and the number of participating sites from province vary to province. DEWS. Human resources in the provincial and district health systems are trained and enabled to utilize The DHIS list is used for IDSR in KP, and DSS in Punjab (mainly syndromic). Syndromic surveillance is functioning for AFP, influenza-like illness (ILI)/SARI, VHF.and conducted. been has exercise prioritization disease A data. laboratory real-time The Ministry of NHSR&C lacks connection to the surveillance system and ongoing collection of systems. surveillance the A mechanism is needed to feed public health lab data from both human and animal into sectors labs. mechanism to integrate data from clinical reporting case and clinical or reference microbiological information systems operating in the health and there sector is aneed for acentrally located There is no standardization (electronic or otherwise) for data collection of different health Linkages health between information systems are not fully established at the national level. No formal mechanism to exists share including reports, lab data, among stakeholders. Utilization of surveillance by decision-makers reports is limited. province. to province from varies data surveillance of integration for mechanism The sharing. information of means A tri-annual seasonal and alert awareness letter, advisories, and weekly bulletins are issued as a programmes. vertical of systems internal through provided is assurance quality and validation Data – – – – – – – – – – – – – – – – – – of Veterinary Research and Diagnosis Tando jam, Sindh, 2016. p. 84 Directorate Province. Sindh of Diseases Zoonotic O. Parkash, Important and P Dewani, Umrami, AP; 2009 (DEWS). Ministry of Health, the National Institute of Health and the World Health Organization. Disease’s Samples including Prevention &Control Measures. Disease Early Warning System Case Definitions and Standard Procedures for Collection and Transportation of Human Infectious (DiseaseDEWS Early Warning and Response System) Manual, 2012 Edition. Disease Prioritization on Workshop of for Surveillance,Report 2015. Dec 8 Punjab, Notification 2005 Disease Protocols for 2015 RegulationsCoordination Pakistan, & Services National Health of Terms of Reference: Technical Working for Group Disease (TWG) Surveillance &Response, Ministry Notification of Technical Working (TWG) forGroup Disease Surveillance & Response 24-11-15. IHR Assessment Mission, Pakistan, 2013. Ebola virus disease preparedness assessment summary, Pakistan 21-12-14. 37 of IHR Core Capacities of the Islamic Republic of Pakistan DETECT 38 DETECT

Joint External Evaluation Timely and accurate disease reporting, according to WHO requirements and consistent coordination with with coordination consistent and requirements WHO to according reporting, disease accurate and Timely trengths/best practices trengths/best S T ecosystems reducestheriskofdiseasesatinterfacesbetweenthem. and animalhealthsystems. Collaborative multidisciplinaryreportingonthehealthofhumans, animals, and pathogens continuetoevolveandadaptnewhostsenvironments, imposingaburdenonhuman Health threats at the human–animal–ecosystem interface have increased over the past decades, as Introduction Reporting provided bytheFood and Agriculture Organization(FAO), OIEand WHO. Information System(WAHIS) NFP; theIHRNFPislinked toalearningpackageandbestpractices as Score 2: Limitedcapacity. Countryhas identified an IHR NFP, OIE delegates and World Animal Health D.4.1 Systemforefficient reporting to WHO Indicators andscores Recommendations forpriorityactions NFPs, butsofartheyhavenotbeenused. The countryisaware oftheimportanceinformalconsultationmechanismswith WHO andotherIHR exchange hasyettobedefinedandexercised. 2 of theIHR, reporting thresholds and cross-sectoral information understanding on the use of Annex This lackofaclearlydefinedmechanismcanputatrisktimelydecisionsandreporting. Also, acommon agreements forregularinformationexchange. hocbasis. Duringoutbreaks, thistakes placeonanad multisectoral meetingsarranged bytheMinistryofNHSR&C. However, thereareneitherformalnorinformal In general, thereisgoodcommunicationbetweensectorsandlevels. During emergencies thereare The Focal Point forOIEisestablishedwithintheMinistryofNationalFood SecurityandResearch. The countryhasdesignatedanIHRNFPintheNIHaswellfocalpointsProvincialHealthDirectorates. P FAO and OIE. and FAO arget akistan levelofcapabilities – – – – – – – – – – other’s needs. relationship active An IHR NFP between and exists OIE Contact Point, who respond to each tested. and animal health authorities, and security although established on an ad hoc basis, have been tried Mechanisms public health, for information between sharing during outbreaks and reporting neighbouring with as countries. Strengthen multilateral or bilateral reporting mechanisms, and provinces sectors between as well Build and reporting training capacity for relevant staff. exchange, SOPs (and legislation, if necessary), for the IHR NFP and OIE Contact Point. Establish permanent formal protocols for the reporting mechanism, zoonotic disease information , FAO andOIE. regulations, and/orlegislationgoverningreportingtostartimplementationwithinayear. Score 2: Limitedcapacity. Countryisintheprocessofdevelopingandestablishingprotocols, processes, D.4.2 Reportingnetworkandprotocols incountry. Relevant documentation Relevant strengthening/challenges need that reas A practices trengths/best S strengthening/challenges need that reas A – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – DSS and HSS Bulletins. HSS and DSS SOPs for RRTs from Ebola. Plan. Action National Emergency SOPs for PoE. international concern; far so this is only in place for polio. SOPs should developed be and implemented based on Annex 2of the IHR for reporting events of for timely decisions. There is a lack of clearly defined national, regional and local reporting mechanisms and thresholds Formally approved reporting need to networks be established. SOPs for PoE are available. SOPs for RRT are defined clearly for response to notifiable diseases and potential events. Identification of other public health events are enabled throughexisting surveillancesystems. level. high Polio surveillance keeps the country’s systems and capacities to events identifyand report at a Points. Contact OIE and A regular and more formal information sharing mechanism should developed be among IHR NFP The multilateral or bilateral reporting mechanism is poor, especially with neighbouring countries. Training is lacking for IHR NFP and OIE Contact Point on reporting. responsibilitiesand acting limit performance. its with WHO; in addition, continuously changing ministries hosting the IHR NFP team, devolution, There is a lack of legislation authorizing the IHR NFP as a national multisectoral communication hub strengthening. The reporting mechanism issues of food safety through the IHR NFP and to the OIE needs high. too is internationally events mechanisms with other IHR NFPs, are not yet in practice; in general the threshold for reporting Informal consultation mechanisms of IHR NFP with WHO, e.g. by telephone, and bilateral exchange counterparts. animal human and sector between Coordination increased has Multisectoral meetings are held to evaluate potential public health threats (Ebola, Zika). 39 of IHR Core Capacities of the Islamic Republic of Pakistan DETECT 40 DETECT

Joint External Evaluation State Parties should have skilled and competent health personnel for sustainable and functional public public functional and sustainable for personnel health competent and skilled have should Parties State T training, scientificskills, andsubject-matterexpertise. by developingandmaintainingthehighlyqualifiedpublichealthworkforcewithappropriatetechnical Workforce developmentisimportantinordertodevelopasustainablepublichealthsystemovertime Introduction Workforce development until 2015. importance insurveillanceandepidemiologicresponse, FELTP madeimportantimprovements from2007 Programme, whichgrewfrom 16districtsin2011to452015. Intheseandotherareasof of FELTP isthecoverage ofdistrictsathighriskforpoliothrough the NationalStop Transmission ofPolio NARC hasenabledimprovedcapacityforpromptdetection ofzoonoticdiseases. Among otherimpacts encompassing training in field epidemiologyforallconcernedin Pakistan. Collaboration andworkingwith established incollaboration with NIH, thePakistan Army andNARC, whoworkwithFELTP tohavemore Additionally, apublichealthnetworkthroughfivesentinelsurveillancesitesforhepatitishasbeen units fortheirfieldtraining. are nowbecomingtheprincipalsurveillancepointsinPakistan, andFELTP fellowsarenowpostedinthese provinces andthefederal governmenttodevelopdiseasesurveillanceandresponseunits (DSRU). These diseases andmeasles, andresponsestonatural disasters. FELTP haspartneredwithallfourPakistani such as primaryamoebicmeningoencephalitis, to commonbut widespread problems such as waterborne for pandemicdiseasessuchas A(H5N1) avianinfluenzaandMERS, torelatively rare butfatalinfections frequent andtimelythroughtheactivitiesofFELTP. These outbreaksresponsesincludedpreparedness 39 arecurrentlyenrolled. Graduates aredistributedthroughoutPakistan. Outbreak responsebecamemore then, 67fieldepidemiologistsfromthepublicsectoracrosscountryhavegraduated fromFELTP and a legalframework fordiseasereporting, andcreateafunctioningpublichealthlaboratory network. Since in fieldepidemiologyandresponse, establishdiseasesurveillanceandoutbreakresponseunits, develop The GovernmentestablishedFELTP in2006toaddressdocumentedneedsto: develophumanresources education andrefreshercoursestoitsworkforce. the publichealthsector, theprovincial departmentsofhealthalsoprovideongoingcontinuingmedical number ofsuchinstitutionsvaries byprovincebasedontheavailability ofinfrastructure andfaculty. In universities atKarachi andPeshawar –providebasicaswell aspost-graduate professionaltraining. The – HealthServices Academy Islamabad, UVSLahore, Agha KhanUniversityandDowKhyberMedical (including laboratory technicians, ladyhealthvisitors, etc.). Somepublicand private academicinstitutions share isspentontheworkforce. This includestraining of physicians, veterinarians, nurses, paramedical staff The GovernmentofPakistan hasbeengenerally allocatinglessthan1%ofitsGDPonhealth, ofwhichamajor P health surveillance and response at all levels of the health system and the effective implementation of the the of implementation effective the and system health the of levels all at response and surveillance health IHR (2005). IHR arget akistan levelofcapabilities reas that need strengthening/challenges need that reas A practices trengths/best S intermediate levels. Score 3: Developedcapacity. Multidisciplinaryhumanresourcecapacityisavailable atnationaland D.5.1 Humanresources are availabletoimplementIHRcore capacityrequirements. Indicators andscores Recommendations forpriorityactions – – – – – – – – – – – – – – – – – – – – – – – – – – – – programmes). control, medical entomology (the Health Academy Services and other institutions training offers There is also aneed for training of professionals in multiple disciplines, including infection with astructuredcareer ladder at national and provincial levels across the country. the government structure for various public health professional categories, such as epidemiologists, Government should allocate resources for sustainable funding to introduce new positions within level. district Strengthening of technical capacities of all cadres is needed not only at the provincial but also at of 1/200 000 trained epidemiologists (or equivalent). There is also alimited number of fully trained epidemiologists and the need is far below the target to limited career opportunities. There are funding constraints which result in attrition of qualified public health professionals due services. health-care primary provide A large workforce of community health-care workers (lady health workers, migrant workers, etc.) FELTP with exists the residents assigned both at national and provincial levels. Punjab has also awell developed Human Resource Information System. implemented. be to needs for trainingcapacity of HRH in exists various Sindh sectors: has developed astrategy that still A human resource for health (HRH) assessment has been completed in some provinces. Indigenous requirements. core IHR Implement to level provincial national and at isavailable both Capacity and other public health personnel), trained in public and private institutions. sector information systems specialists, veterinarians, social scientists, laboratory technicians/specialists biostatisticians, epidemiologists, available are (physicians, disciplines various in resources Human Develop placement acareer structure for effective and retention of eligible and qualifiedcandidates. health. animal and human in both workforce Develop specific eligibility and qualificationstandards for various cadres of the public health training, recruitment and retention. national Eastern or WHO Mediterranean Regionaltargets) Office for variouscadres, strategy for Develop acomprehensive public health workforce to policy address specifictargets (based on 41 of IHR Core Capacities of the Islamic Republic of Pakistan DETECT 42 DETECT

Joint External Evaluation professions (e.g. epidemiologists, veterinariansandlaboratory technicians). Score 2: D.5.3 Workforcestrategy. applied epidemiologytraining programme isinplacePakistan. Score 3: Developedcapacity. OnelevelofFELTP (basic, intermediateoradvanced) orcomparable programme inplace. trengths/best practices practices trengths/best S D.5.2 FieldEpidemiology reas that need strengthening/challenges need that reas A practices trengths/best S strengthening/challenges need that reas A – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – need to be implemented. be to need Sindh and Punjab provinces have developed their human resource strategies; however, they still HRH nor policy any structuredhuman resources department. Although an HRH assessment has been completed in some provinces, there is neither anational provinces. in some Management exist cadres provinces. Incentive-based retention for exists health professionals in Punjab and KP. Incentives (hardship allowances) are given to retain the existing health workforce within some Sindh and Punjab provinces have and human resource strategy. FELTP training should have recognition/registration within appropriate forums/registering bodies. Mechanisms should developed be at the international level for cooperation and collaboration. placement of field epidemiologist in each district of the country. placementEffective and utilization of FELTP graduates in the field shouldbe encouragedwith professionals. academic for cater also The field epidemiology training programme onlytargets the public health workforce and should post-graduate level training and degrees (Master of Public Health, MPhil, of Philosophy). Doctor Public health training programmes exist in both public and private institutes that graduate offer and epidemiology. Public health professionals are also being trained at private institutions/universities sector in Pakistan; comprising FELTP graduates and trainees. This programme has also helped establish the National Stop Transmission of Polio Programme in has also helped establish and train thefor first cohort Afghanistan FELTP. events through the Eastern Mediterranean Public Health (EMPHENET). Network The programme Partnerships exist with other countries in the region to share FELTP graduates during emergency trainingoffers both toin officers in-service health and veterinarysectors. FELTP programme has 67 graduates. In addition to the advanced programme, two-year it also programmes. short-term and long- regular Authority institutions in all four provinces exist where public health professionals are trained on Services Health Council/Provincial Doctors Homeopathic Academy, Pakistan Services Health Limited capacity. A health-careworkforcestrategy existsbutdoesnotincludepublichealth T raining Programme orotherappliedepidemiologytraining Relevant documentation Relevant – – – – – – – – – – – – – – Human Resource Development plan for National Disaster Management (NDMA). Authority FELTP at aglance 2015 report, RRT,reports. trainings) (IHR, Lab Training workshop Sindh Human Resources strategy, Powerpoint Presentation, Sindh Department of Health. 2015 Provincial Human Resources profiles. Resources Human Provincial presented to EET during mission) Government of Pakistan presentation on self-assessment of JEE in Pakistan (as provided and specialties’ or animal health professionals), there is no uniformity in such incentives. provinces (e.g. physicians, veterinarians, nurses, biostatisticians, assistants, laboratory other While specific monetary/other incentivesexist to retain the public health workforce somein l l l

Sindh, 2013Sindh, 2012Punjab, Balochistan 43 of IHR Core Capacities of the Islamic Republic of Pakistan DETECT 44 RESPOND

Joint External Evaluation The effective implementation of the IHR (2005) requires multisectoral/multidisciplinary approaches through through approaches multisectoral/multidisciplinary requires (2005) IHR the of implementation effective The emergency. to supportoperations attheintermediateandcommunity/primaryresponselevelsduringapublichealth the identificationandmaintenancesofavailable resources, includingnationalstockpiles, andthecapacity radiological andnuclearhazards. Othercomponentsofpreparednessincludemappingpotentialhazards, primary responselevel, andpublichealthemergencyresponseplansforrelevant biological, chemical, Preparedness includesthedevelopmentandmaintenanceofanational, intermediateandcommunity/ Introduction Preparedness RESPOND provincial/regional contingency andpreparednessplansdevelopedannually. Management Framework (2007), UnitedNationsInter-Agency PreparednessPlan(2014), andrespective Industrial Technical Disasters, NationalMonsoonContingencyPlan(updatedyearly), NationalDisasterRisk (2011), NationalDisaster Risk ReductionPolicy (2012), NationalContingency Plan2010toManage the National Epidemic and Pandemic Preparedness Plan (2014), the Avian Influenza Preparedness Plan precluded the finalization of the plan. Other national level hazard-specific preparedness efforts include WHO initiatedthe All-Hazard NationalEmergency Preparedness Plan in2014, but lack of resources preparedness andresponseplanningimplementation inconsultationwiththeNDMA. HEPRNand management andcoordinationentitiesinhealth. HEPRN ledthemultisectoral andall-hazardshealth preparedness andresponsenetworks(HEPRN)atfederal andprovinciallevels, astheassignedcrisis agency forhealth, andtheformerMinistryofHealth, worked togethertoestablishhealthemergency Following themega-flooddisasterof2010–2011, WHOastheUnitedNationshumanitarianclusterlead reduction proceduresandpolicies. vital role in the preparation of monsoon contingency plans as well as earthquake, flood and disaster risk Preparedness andResponseNetwork(NHEPRN)was establishedin2010. NDMA hasbeenplayinga warning systems, andmaintenanceofinventories. With supportfrom WHO, theNationalHealthEmergency preparedness inPakistan includescapacity-building, developmentofemergencyresponseplans, effective provincial healthdepartmentstorespondrapidly andeffectivelytodisastersituations. Healthemergency authorities, thenationalandprovincialhealthemergencypreparednessresponse(EPR)networks, and Thus preparedness, aprotectiveprocess, hasenablednationalandprovincialdisastermanagement event aimedatminimizinglossoflife, disruptionofcriticalservices, anddamagewhenthedisasteroccurs. Health emergencypreparednessinPakistan encompassesallmeasurestaken beforeadisasterorsevere P T national partnerships for effective alert and response systems. Coordination of nationwide resources, resources, nationwide of Coordination systems. response and alert effective for partnerships national including the sustainable functioning of a National IHR Focal Point (NFP), which is a national centre for IHR IHR for centre national a is which (NFP), Point Focal IHR National a of functioning sustainable the including (2005) communications, is a key requisite for IHR (2005) implementation. The NFP should be accessible accessible be should NFP The implementation. (2005) IHR for requisite key a is communications, (2005) at all times to communicate with the WHO IHR Regional Contact Points and with all relevant sectors sectors relevant all with and Points Contact Regional IHR WHO the with communicate to times all at and other stakeholders in the country. States Parties should provide WHO with contact details of NFPs, NFPs, of details contact with WHO provide should Parties States country. the in stakeholders other and continuously update and annually confirm them. confirm annually and update continuously arget akistan’s levelofcapabilities development ofpoliciesandformulationmulti-hazardhealthemergencyplans. At theprovinciallevel, healthdepartments, PDMAsandprovincialHEPRNssupportcontributetothe trengths/best practices trengths/best S to meettheIHRcorecapacityrequirements(Annex1A Article 2). Score 1: Nocapacity. Nonationalpublichealthemergencypreparednessandresponseplanisavailable developed andimplemented. R.1.1 Multi-hazard NationalPublicHealthEmergency Preparedness andResponsePlanis Indicators andscores Recommendations forpriorityactions – – – – – – – – – – – – – – – – – – – – – – – – – – – – disaster risk management activities. activities. risk management disaster NHEPRN has engaged all stakeholders to ensure involvement and community participation in relevant and district sectors administrations. the needs country are prepared by and NDMA provincial plans involving by respective PDMAs all SOPs for PoE for Ebola were developed in 2014; national emergency response plans specific to EbolaAn preparedness assessment was conducted in 2014 with of the WHO. support plans forand areas) KP Northern and provincial PDMAs with NDMA, health departments. National/provincial contingency plans are available (monsoon-related as well as winter contingency airports. (PoE) Airport ContingencyAn Plan with exists apublic health emergency component at main 2011. Plan Pakistan has developed disease-specific preparedness and response plans, e.g. Avian Influenza implementation. NationalA draft Epidemic and Pandemic Preparedness Plan is available for adoption and Preparedness and Response Plan have been conducted. Emergency Health Public National Multi-Hazard the on workshops consultative Provincial programmes. development and preparedness between Invest and awareness in advocacy for and policy- decision-makers to ensure adequate linkages Advocate at all levels to promote, prioritize, and invest in preparedness rather than response. based disaster risk reduction prescribed under the Sendai Preparedness Framework of 2015. multisectoral, all-hazards public health EPR plan. This plan should include elements of community- Conduct hazards/risk mapping at the national and provincial levels and develop anational level, chasm and public NDMA its between health goals and objectives. sector. This should entity also as the technical serve to to NDMA body bridge advisory the existing Establish a One Health strategy development and implementation to ledbody be by the health Adopt legislation NDMA and delegate all public health-related functions to the health sector. in the wake of an emergency. formulation of required policies and plans on health EPR when formally asked by the Government international NGOs coordinate at the national level to provide technical assistance for the agencies/ Nations United implementation. for relevant stakeholders the with collaborates NHEPRN in consultation with develops NDMA required emergency preparedness plans and 45 of IHR Core Capacities of the Islamic Republic of Pakistan RESPOND 46 RESPOND

Joint External Evaluation Score 1: Nocapacity. Publichealthriskandresourcesmappingisnotdone. R.1.2 Prioritypublichealthrisksandresources are mappedandutilized. reas that need strengthening/challenges need that reas A reas that need strengthening need that reas A practices trengths/best S – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – need to be established. A regular mechanism for budget allocations to the district authorities and relevant departments earlyAn warning system at national and provincial levels should institutionalized. be Plan need to endorsed be and implemented. The National Epidemic and Pandemic Preparedness Plan and National Emergency Preparedness Annual refresher training of RRTs for preparedness and response is aregular feature. RRTs are notified at federal level and in three provinces (Punjab,KP and Baluchistan). Monsoon contingency plans are prepared and other yearly relevant by NDMA/PDMA departments. In all provinces, high risk are districts notified by PDMA for monsoon rains/floods year. every influenza). avian response, (cholera emergencies outbreak foreseen/unforeseen plans for preparedness a has NHEPRN A one-month stock of medicines and supplies is for reserved emergencies at all levels. Resource mapping for vertical health programmes has been done at limited levels. Risk mapping for polio is achieved and partially for achieved for dengue in Punjab. areas. emergency/conflict when) in primarily WHO/health cluster profiling partner is done through the 4W matrix (who,what, where and The annual budget of has NDMA been increased from two-fold 2012 to 2013. planning. hasNDMA been strengthened by the addition of arms such as climate change adoption and policy The various available preparedness plans need to integrated be into one comprehensive plan. resources. Finalization of the All-Hazard National Emergency Preparedness Plan is pending due to lack of plans. these implement to required are allocation and availability Resource levels. provincial and federal at implementation plans for operational The National Pandemic Preparedness Plan 2014 needs endorsement and translation into preparedness. emergency for resources and limited has capacities NHEPRN mobilization. resource A holistic approach and the involvement of all relevant stakeholders is needed for optimum procedures. plans and emergency health of stakeholders (United Nations/WHO, Ministry of NHSR&C, HEPRN, NDMA, etc.) for the formulation Technical capacities of the HEPRN should enhanced be and collaboration improved all between Punjab health department allocates 15% budget of its for emergencies at all levels. The United Nations cluster approach is adopted during emergencies for acoordinated response. Relevant documentation Relevant – – – – – – – – – – – – – – – – – – – – Inter-agency plan preparedness 2014- UN. SOPs for for POE Ebola 2014- Draft. Pakistan Ebola preparedness assessment mission 2014. report 2007. Risk Framework Management National Disaster National Contingency Plan to Manage Industrial/Technical Disasters. 2015. Plan Contingency Monsoon National National Disaster Response Plan 2010. 2014. Plan Preparedness Pandemic National National Disaster Management 2010. AuthorityAct supplies.and A regular mechanism should set be up for resource mapping and stockpiling of essential medicines 47 of IHR Core Capacities of the Islamic Republic of Pakistan RESPOND 48 RESPOND

Joint External Evaluation Countries will have a public health Emergency Operation Center (EOC) functioning according to minimum minimum to according functioning (EOC) Center Operation Emergency health public a have will Countries coordination, andcollaboration. exercise. They alsoprovideotheressentialfunctionstosupportdecision-makingandimplementation, information toolsandservicesamanagementsystemduringresponsetoanemergencyor management ofpublichealthemergenciesandemergencyexercises. EOCsprovidecommunicationand center (EOC)isacentral locationforcoordinatingoperational informationandresourcesforstrategic and respondtoemergenciesinaneffectiveatimelyfashion. A publichealthemergencyoperations Emergency responseoperations includetheplans, policies, programs, andsurgecapacitiestocoordinate Introduction operations response Emergency centralized OneHealth EOCauthorizedtocoordinate withallstakeholders tomanagehealthevents and/ at thenational, provincial anddistrictsleveltoeventsthatexceedlocalcapacity. However, thereisno NDMA anditsprovincialarms –PDMAshaswellstructuredEOCstocoordinate emergencyresponse and responsewherewarranted. level andinafewprovinces undercorrespondingheathauthoritiesandperformoutbreak investigations to outbreaks, andparticularlytothethreatofEbola, RRTs havebeentrained andareavailable atnational of institutionaldevelopmentinasystematic, predictable, andconsistentmannerhasdwindled. Inresponse health sector. HEPRNhasreceivedsupportfromtheUnitedNationsandotherdonors. However, continuation NHEPRN was establishedfollowing the2010floodsashealthemergencyresponseleadentityin from thegovernmentside. health clustercoordinationandresponseagency, whichcollaborated withthe Ministry ofHealth/NHSR&C earthquake. Formal activation occurredforthe2010floods, andconflictinthenorth. WHO wasthelead cluster response system was also informally activated and implemented in Pakistan to address the 2005 supported bytheUnitedNations/WHOwhenneeded. The UnitedNationsinter-agency humanitarian to date. HealthemergenciesandtechnicalaspectshavebeenhandledbytheMinistryofHealth/NHSR&C NDMA isthemostcomprehensiveandadvanced emergencyresponseandcoordination entityestablished and Rehabilitation Authority establishedin2005, andtherecentNDMAestablished post-floodsin2010. These includetheDepartmentforManaging Afghan Refugees’ Affairs inthe1990s, theEarthquake Recovery As aresultofrecurrentcrises, several emergencyresponseagenciesanddepartments havebeenestablished. are anearlyannualchallenge. 2010–2011 withasubsequentcholera outbreak. Varying levelsoffloodsbroughtaboutby monsoon rains influx of Afghanrefugeesinthelate1980sand1990s, Pakistan’s earthquake of2005, andmegafloodsin north. Significantinternationalsupportandemergencyresponseassistancearrivedfollowingthemassive border conflict, communicable disease outbreaks, intentional mass casualty events, and internal strife in the in Pakistan havebeenrepeatedlytestedbytheincreasingscaleandmagnitudeofnatural disasters, cross- Since thestartof the Afghan conflict inthe1980s, emergencyresponsecapacitiesofrelevant authorities P T common standards; maintaining trained, functioning, multi-sectoral rapid response teams and “real-time” “real-time” and teams response rapid multi-sectoral functioning, trained, maintaining standards; common biosurveillance laboratory networks and information systems; and trained EOC staff capable of activating activating of capable staff EOC trained and systems; information and networks laboratory biosurveillance a coordinated emergency response within 120 minutes of the identification of a public health emergency. health public a of identification the of minutes 120 within response emergency coordinated a arget akistan levelofcapabilities trengths/best practices trengths/best S to guideresponse. Score 2: Limitedcapacity. EOCpointofcontactwiththesupportpartners’resources isavailable 24/7 R.2.1 Capacitytoactivateemergency operations. Indicators andscores Recommendations forpriorityactions unique opportunityforthecountrytoadoptandsustainafter-polio eradication. operational equipment, surgecapacitytraining, mobilizationanddeployment)offersbestpractices anda emergency responsecoordinationstructure(procedures, operations, humanresources, otherlogisticaland staffed EOCsatnationalandprovinciallevelsinthehealthsector. Underthepolioprogramme, thewhole assets andcapacitieshaveincreasedsignificantly. Currently, poliohasfunctioningandwellequipped and public healthemergencyofinternationalconcernunderIHR, emergencycoordinationandresponse is oneofthelasttworemainingcountriesstillaffectedbydisease. After declaration ofpolioasa The polioprogramme hasgarneredunprecedentedattention, supportandfocusbecausegloballyPakistan exercises. exercises areheldonregularbasis; additionaldrills, table-topexercisesandsimulationssupplementthese emerging diseasethreats. NDMAconductsexercisesondisasterriskmanagementatalllevels. Functional National emergencyoperational planshavebeendevelopedtoaddressdifferenthealthemergenciesand structure andoperational functionstolead, coordinate, andmanage/enforcehealthemergencyresponse. respective levels. However, theylackthelegislativefoundation, politicalsupport, finances, administrative developed andapprovedaNHEPRNprovincialHEPRNtocoordinaterespondeventsattheir or disasterswithhealthimpact; thisfindingextendstoprovincesanddistricts. The MinistryofNHSR&C – – – – – – – – – – – – – – mechanisms are in place for polio training fieldstaff at all levels. provide technical and human resources to support the EOC functions. Specific guidelines and WHO, the United Nations Children’s Fund (UNICEF) and the Bill &Melinda Gates Foundation emergency. of level the to according activation levels provincial for and federal takesNDMA alead role in response and coordinates with relevant health authorities at the emergency. health public a declared being EOCs have been established at all levels since 2015 and remain constantly due active to polio operations. response and EOCs sustain to resources strengthen capacities to manage IHR-related hazards including finances and training human Create, based on the One Health strategy implementation body, cross-cutting processes to incorporate this perspective. beyond EPI and/or polio, and regularly review and update emergency procedures and plans to theExpand existing polio/EPI EOCs to cater to other One Health-related hazards and emergencies Health approach. and efficient, evidence-basedeffective, coordination and response to health threats underOne a work under, and obtain authority and from its thesupport governing structure of for NDMA an can body plan. This multi-hazard and multi-disciplinary collaborative, integrated, response, and NHSR&C, to coordinate, manage, develop, enforce, and sustain aOne Health event management Adapt or develop a‘One Health Emergency Response Operation’ led by body the Ministry of Develop amultisectoral, all-hazards, national health EPR plan based on ahazards/risk profile. 49 of IHR Core Capacities of the Islamic Republic of Pakistan RESPOND 50 RESPOND

Joint External Evaluation Incident managementorcommand, operations, planning, logisticsandfinance). equivalent areinplace; aplandescribeskey structural and operational elementsforbasicroles(including Score 2: R.2.2 Emergency Operations Centre Operating ProceduresPlans. and reas that need strengthening/challenges need that reas A in placetostrengthenemergencyresponseatthefederal andprovinciallevels, including: Pakistan ispronetonatural disastershavingasignificanteconomicimpact. However, anumberofplansare practices trengths/best S – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – National Emergency Action Plan (updated yearly/endorsed by Prime Ministers National Task Ministers Prime by Plan (updated yearly/endorsed Force). Action National Emergency 2013 Policy Risk Reduction National Disaster 2007 RiskFramework Management National Disaster National Contingency Plan to Manage Industrial/Technical Disasters Plan (updated yearly) Contingency National Monsoon National Disaster Response Plan 2010 2014 Plan Preparedness Pandemic National Plan 2010 Response Humanitarian Pakistan There is alack of specificallocation budgetary for emergencies at the provincial level. addressed. be should constraints Funding A hotline should established be to respond to disease outbreaks. strengthened. Community engagement and mechanisms to manage emergency response activities should be operations. emergency well coordinated Collaboration the public between and United sector Nations agencies should strengthened be for mobilization of resources. A holistic approach should adopted be to ensure involvement of all relevant stakeholders for the inmore the context of effectively aOne Health approach. National and provincial HEPRN need to strengthened be to coordinate the emergency response to other public healtheffectively emergencies besides polio. The scope and mandate of EOCs need to enhanced further be and strengthened to respond emergency. The Strategic Health Operations Centre byat WHO NHEPRN activated can be during any is well established. approach cluster health emergency The together and operate the EOC for acoordinated polio response. Six polio-specific EOCs are established at the national and provincial levels.All stakeholders sit Coordinator’s Office. In provinces, the health have departments round the clock functional control rooms in the District Limited capacity. EOC plans/proceduresdescribingincidentmanagementstructureor minutes oftheidentificationapublichealthemergency. ties. However, thesystemisnotyetcapableofactivating coordinated emergencyresponsewithin120 Score 3: Developedcapacity. Afunctionalexercisehasbeencompletedtotestoperational capabili- R.2.3 Emergency Operations Programme. trengths/best practices trengths/best S strengthening/challenges need that reas A operation reflectedby: made risksandthreats, Pakistan obtainedbestpractice experienceandcapabilityinitsemergencyresponse Due tothehighnumberofemergencyeventsrelatedclimateandnatural disasters, coupledwithman- – – – – – – – – – – – – – – – – – – – – – – – – – – – – A hotline to call for help on handling adisease of unknown origin in Punjab. Disaster risk management plans being in place Disaster drills and exercises conducted by NDMA annual basis on plans updated emergency Flood Financial constraints and insufficient technicalcapacities shouldbe addressed at all levels. ensure implementation effective of the One Health approach. Linkages should established be with the and NDMA PDMAemergency response operations to plans. emergency and procedures of formulation/upgrading a for departments Adoption of the One Health approach to integrate all relevant and concerned public sector Rapid response and security exercises are conducted. simulation exercises. yearly include PDMA and NDMA Most national and provincial emergency response operations and programmes conducted by routine immunization and polio activities. Services; Director EPI is also the EOC Coordinator for management and coordination of both In Punjab, EOC is placed in the EPI Directorate of the Director atGeneral the Office of Health functionsand in supports relation to One Health event management and preparedness including: Authority should adapted be through delegation of the legislation NDMA that enforces, funds legislation. and There are insufficient and efficient evidence-basedprocesses, policies effective and procedures, the value of the One Health approach. Communication need to enhanced be to provide information and advice on the importance and disaster drills and exercises. through establishing aOne Health EOC equipped with all requirement to address routine events, to IHR and to build capacities to respond to multisector emergencies of public health concern, and institutionalized linkages This to the is NDMA. essential to bridge the technical gaps in relation There is aneed to adopt the One Health approach for health emergency operations, with close l l l

federal and provincial levels. provincial and federal the at both agencies management disaster between coordination and integration improved plan Emergency National Health Multi-Hazard the of implementation and testing mapping all stakeholders and responding bodies to One Health events, and regular update, regular conduct of multi-hazard national and provincial risk assessments

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Joint External Evaluation diseases. Score 2: Limitedcapacity. Casemanagementguidelinesareavailable forpriorityepidemic-prone R.2.4 Casemanagementprocedures are implementedforIHRrelevant hazards.

trengths/best practices trengths/best S reas that need strengthening/challenges need that reas A – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – hazards at all health system levels. system all health at hazards like A(H1N1), CCHF, dengue haemorrhagic fever, diphtheria, leishmaniasis and IHR-relevant epidemic-prone diseases priority guidelinesavailable management are for disseminated Case and emergency response operation reflected by: reflected operation response emergency with man-made risks and threats, Pakistan obtained practice best experience and capability in its coupled related climate to naturaldisasters, and events emergency of number high the to Due No mock exercises have been carried out during the last year. are requiredConcerted to efforts expand the polio-specific EOCs into overall emergency operations. A hotline should established be for response to disease outbreaks. activities. Community engagement and mechanisms should strengthened be to manage emergency response public for health. department There is aneed to create amultisectoral commission/multi-disciplinary emergency response Defined terms of reference andpolicies are not in place to respond to emergencies. risk on isCapacity-building also communication needed and appropriate information sharing. operations. emergency in relevantline departments the for isneeded Capacity-building emergencies. EOCs should strengthened be to respond to all notifiable/priority diseases and public health diseases. infectious NIH as the National Reference has Laboratory for the detection capacity and surveillance of major health departments. Response to disease outbreaks such as cholera, CCHF, dengue, A(H1N1) is functioning through resources. The health cluster approach has proven and avoids effective duplication and waste of of efforts throughpartners the health cluster. implementing and departments health provincial NHEPRN, supports operations emergency WHO Round the clock EOC for exists polio. l l l l

In Punjab, ahotline is available to call for help on handling disease outbreaks. Disaster risk management plans are prepared with of the WHO/UNICEF support Disaster drills and exercises are conducted by NDMA annual basis on plans updated are emergency Flood Relevant documentation Relevant strengthening/challenges need that reas A 2012 withthesupportofWHO. Case definitionandmanagement guidelines ofnotifiablediseases were established in – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – National Emergency Action Plan (updated yearly/endorsed by Prime Ministers National Task Ministers Prime by Plan (updated yearly/endorsed Force). Action National Emergency Plan. Response Humanitarian Pakistan Policy, 2013. Risk Reduction National Disaster 2007. Risk Framework, Management National Disaster National Contingency Plan to Manage Industrial/Technical Disasters. Plan (updated yearly). Contingency National Monsoon 2010. Plan, Response Disaster National NationalDraft Pandemic Preparedness Plan, 2014. Availability of resources allocation and budgetary needs to increased. be at other PoE (land crossings and sea ports). SOPs for the management and transport of potentially infectious patients should also available be IHR-related events such as avian influenza, CCHF and Ebola. Limited in exists the hospital capacity for setting infection prevention and management case of levels across the country. Guidelines for AFP surveillance, investigation and management case are being followed at all Provincial RRTs are trained in management case of IHR-related emergencies by WHO. Patient referral and transportation mechanisms with adequate resources are partially available. of entry. SOPs are available for the management and transport of potentially infectious patients and point 53 of IHR Core Capacities of the Islamic Republic of Pakistan RESPOND 54 RESPOND

Joint External Evaluation In the event of a biological event of suspected or confirmed deliberate origin, a country will be able to to able be will country a origin, deliberate confirmed or suspected of event biological a of event the In T in ordertominimizelossoflife, orinjury, andforoptimalpublicsafetysecurity. a publichealthemergency, lawenforcementandpublichealthsystemsneedtocoordinatetheirresponse casualty events)andinnatural disasters(e.g. pandemics, earthquakes, flashfloods, tsunami, hurricanes). In displacements, posespecialchallengesforlawenforcementbothinman-madecrises(e.g. intentionalmass Major publichealthemergencies, especiallythosewithsocietalimplicationsand/orlargepopulation Introduction authorities security and health public Linking authorities, commitment of resources, rolesandresponsibilitiesofhealth lawenforcementandsecurity and ProvincialHealthEmergency PreparednessandResponsePlans. The SOPsshouldclearlydefinethe for apromptandappropriate response. The SOPsshould bedevelopedwithintheframework oftheNational enforcement andsecurityagencies, SOPsareimportanttocementandaccelerate thecoordinationneeded to developmemoranda ofunderstandingbetweenpublic health, animalhealth, foodsafetyandlaw Although theexistingstructures, statutesandthe rules ofbusinessinPakistan mayobviatetheneed diminish therisksandmaintaincontinuityofprogramme operations. 2012. Sincethen, importantlessonshavebeenlearnt andinnovative strategies progressivelydevelopedto Pakistan facedanunprecedentedchallengewithaseries offatalattacksonhealthworkers thatbeganin strategy tomitigatetheriskof attacksonhealthworkers involvedinthepolioeradication programme. In addition to NDMA and PDMA, a current best practice in Pakistan is a highly coordinated and integrated operation. Commission canrequestforlawenforcementagencies andarmyassistanceforacoordinatedrelief in responsetoaneventordisaster. Inahealtheventorhazardofunparalleled consequencestheDeputy Commissioner withintherulesofbusinesshasauthoritytodirectandcoordinatealllinedepartments multisector responseinvolvingpublichealthandlawenforcement. At thedistrict level, theDeputy At theprovinciallevelPDMAliaiseswithanddistricthealthauthoritiestocoordinatea Nations agencies–workthroughandformpartoftheNDMAtoconducta ‘single window’operation. – includinggovernmentministriesanddepartments, armedforces, internationalandotherNGOs, United in responsetoawidespectrumofdisastersandemergencies. Intheeventofadisaster, allstakeholders The NDMAistheleadagencyatfederal level, whichismandatedtomanageand coordinateactivities public healthandlawenforcementintheresponse. disasters has led to the establishment of strong institutions that have the statutory authority to engage both nationalandinternationalstakeholders. This substantialcumulativeexperience withemergenciesand A(H1N1) influenza, dengue, measles, polio). These havenecessitateda multisectoral responseinvolving food and nutrition insecurity, intentional attacks on health workers and infectious disease outbreaks (e.g. Pakistan hasfacedmultiplemajornatural disasters, includingfloods, earthquakes andmudslidesaswell Level ofcapabilities conduct a rapid, multisectoral response, including the capacity to link public health and law enforcement, enforcement, law and health public link to capacity the including response, multisectoral rapid, a conduct and to provide and/or request effective and timely international assistance, including to investigate alleged alleged investigate to including assistance, international timely and effective request and/or provide to and use events. use arget trengths/best practices trengths/best S exists betweenpublichealthandsecurityauthoritieswithinthecountryhasbeenformallyaccepted. Score 3: Developedcapacity. Amemorandum ofunderstandingorotheragreement(i.e. protocol) Customs) are linked duringasuspectorconfirmedbiologicalevent. R.3.1 PublicHealthandSecurity Indicators andscores Recommendations forpriorityactions Weapons. and theUNSecretaryGeneral’s MechanismforInvestigationof Alleged UseofChemicalandBiological of engagementwithinternationalentitiesandmechanismssuchasInterpol, UnitedNationsagencies, should involvepublichealth, lawenforcement, foreignaffairsandothersectors, andshouldincludeterms weapons, SOPsshouldbedevelopedtofacilitatejointinvestigationsandcoordinatedresponse. The SOPs organizations forthejointinvestigationofeventsrelatedtopossibleintentionalusebiologicalortoxin In theabsenceofanyformalagreementbetweenrelevant nationalauthoritiesandinternational and isanimportantbenchmarktoguidethedevelopmentofsuchSOPs. current linkagebetweenpolioeradication andlawenforcementtooksometimetodevelopmature, sharing, jointinvestigations, jointriskassessments, coordinatedcontrolactivitiesandlawenforcement. The chemical andradiation hazards, andintentionaluseofbiologicalagents. These allrequireinformation Events mightincludediseaseoutbreaks, eventsatpointsofentry, quarantine issues, foodcontamination, agencies, particularlythelocalpolicethatarespecificto various typesofhealtheventsandhazards. – – – – – – – – – – – – – – – – – – major disasters along with provincial of departments health. The Pakistan Army has an enormous medical infrastructure that is engaged during response to programme. agenciessecurity to mitigate the riskon health of attacks workers involved in the polio eradication There are highly coordinated and integrated strategies developed jointly by public health and to both direct health and law enforcement to respond to an event. At the district level, Commissioner, the Deputy as the chief executive of the district, is empowered provincial and district levels to request assistance from the police and other assets. security The ‘Rules of Business’ in the Government of Pakistan enable the public health at federal, service rehabilitation operations. relief and or rescue, law enforcement, National statutes enable the civil government to call in the army to assist with any event requiring army when there is adisaster or major hazardous event. and provincialNDMA its have counterpart, PDMA, clear protocols that engage the police or the conduct simulation exercises to test them and reinforce the training. Provide training in-service for public health personnel and security at all levels on the SOPs and Plans. Response and Preparedness Emergency Health Provincial and National Finalize the agencies. security lawand enforcement and should clearly define the authorities, commitment of resources, roles and responsibilities of health of the National and Provincial Health Emergency Preparedness and Response Plans. The SOPs Establish SOPs for coordination across public health within sectors and the security framework Authorities (e.g. LawEnforcement, Border Control, 55 of IHR Core Capacities of the Islamic Republic of Pakistan RESPOND 56 RESPOND

Joint External Evaluation Relevant documentation Relevant strengthening/challenges need that reas A – – – – – – – – – – – – Health Threats. 2002. Framework Document, Academic Centers for Public Health Preparedness. to Protect the Nation from Bioterrorism, Infectious Disease Outbreaks and Other Emergent Public of SchoolsA Network of Public Health Partnering with State and Local Health Agencies and CDC 2014. (IASC). Standing Committee Inter-Agency Inter-Agency Real Time Evaluation of the Humanitarian Response to Pakistan’s 2010 Flood crisis. (OCHA). Humanitarian affairs Coordination of Inter-agency preparedness plan, Pakistan, Asia, 2014. IASC, United Nations for the Office responses. and investigations joint and sharing, health authorities and security on topics related to specific roles and responsibilities, information There is an absence or lack of training at regional and national levels that includes both public finalized. be The National and Provincial Health Emergency Preparedness and Response Plans should rapidly emergency. health a to response multisectoral There is alack of SOPs to guide the actions of different stakeholders in ahighly coordinated A national framework for transferring (sending and receiving) medical countermeasures and public health health public and countermeasures medical receiving) and (sending transferring for framework national A Recommendations for priority actions Recommendations for priorityactions appropriate training, procedures andmaterials, couldbenefittheemergencyresponse. Pakistan is a disaster-prone country, having a comprehensive plan of mobilization of health personnel, with health emergencies. Issuesoflicensureandliability foreignmedicalpersonnelshouldberegulated. As and internationalmanufacturersand/ordistributorsto procuremedicalcountermeasuresduringpublic and deployment of human resources. There are no formal mechanisms for agreements with national and sending medical countermeasures and health personnel, stockpiling of essential countermeasures Some areascouldbefurtherstrengthenedandreinforced, i.e. developingacomprehensiveplanforreceiving like medicine, equipment, ambulancesetc. during emergencies. one provincetoanotherandvalidated amechanismforfacilitationofreceivingmedical countermeasures to receivemedicalcountermeasuresduringemergencies. The countryhasdeployed healthpersonnelfrom country thereisamechanisminplacetodeclareanemergency, whichallowsvarious levelsofgovernment its supporttodisaster-stricken countrieswithmedical countermeasuresandhealthpersonnel. Within the as flooding, earthquakes andsomediseaseoutbreaks(dengue). Similarly, Pakistan hasbeenextending Pakistan hasexperienceofreceivingmedicalcountermeasuresandhealthpersonnelduringdisasterssuch international supportduringemergenciesinPakistan. countries, an Emergency Relief Cell (Cabinet Division, Government of Pakistan) acts as focalpointwith Any aids to health are presently coordinated by the Ministry of Inter-Provincial Coordination. To assist other and healthpersonnel. Pakistan has a process of regulatingany local orinternational donation ofdrugs. National DisasterResponsePlancontainprovisionsforsendingand/orreceivingmedicalcountermeasures as provincialordistrictDisasterManagement Authorities. The NationalDisasterManagementPlanandthe and formpartoftheNDMAtoconductintegrated operations. A similarstructureexistsatsubnationallevel organizations, thearmedforces, internationalandotherNGOs, UnitedNationsagencies–workthrough activities. Intheeventofadisaster, allstakeholders –includinggovernmentministries, departmentsand The NDMA is the lead agency at the federal level to deal with thewhole spectrum ofdisastermanagement P T emergency forresponse. health. Inaddition, itisimportanttohavetrained personnelwhocanbedeployedincaseofapublichealth catastrophic infectiousdiseasethreats. InvestmentsinMCMcreateopportunitiestoimproveoverall public Medical Countermeasures(MCM)arevitaltonationalsecurityandprotectnationsfrompotentially Introduction deployment countermeasuresMedical andpersonnel and medical personnel among international partners during public health emergencies. health public during partners international among personnel medical and arget akistan levelofcapabilities – – during a public health emergency. emergency. health public a during mechanisms, including roles and responsibilities related to sending and receiving health personnel Develop acomprehensive plan and strategy that identifies procedures and decision-making 57 of IHR Core Capacities of the Islamic Republic of Pakistan RESPOND 58 RESPOND

Joint External Evaluation previous yearinwhichhealthpersonnelweresentorreceived bythecountry. Score 4: Demonstrated capacity. AtleastoneresponseORformalexerciseorsimulationwithin the emergency. R.4.2 Systemisinplaceforsendingandreceiving healthpersonnel duringapublichealth Indicators andscores trengths/best practices trengths/best S strengthening/challenges need that reas A practices trengths/best S previous yearinwhichmedicalcountermeasuresweresentorreceivedbythecountry. Score 4: Demonstrated capacity. AtleastoneresponseORaformalexerciseorsimulationwithinthe health emergency. R.4.1 Systemisinplaceforsendingandreceiving medicalcountermeasures duringapublic – – – – – – – – – – – – – – – – – – – – Some institutes areof GOARN part and network participated in outbreak responses. mobilization is coordinated through the Ministry of Foreign and Affairs the Pakistan Army. within the past year (e.g. medical team mobilization in response to Nepal earthquake). This Pakistan has experience of sending and receiving health personnel in the past, some of which emergencies. health public during countermeasures medical procure to distributors and/or manufacturers A mechanism should established be to have an agreement with national and international outside of the country. improvedbe with development of adistribution plan during public health emergencies within and could provinces vulnerable national and at level countermeasures medical essential Stockpiling of Certificates). Objection No of Issuance for (Policy emergencies during etc. ambulances A mechanism is in place for receiving medical countermeasures like medicine, equipment, earthquake). some of which were within the past year (e.g. medical countermeasures in response to Nepal Pakistan has exercised plans for sending and receiving medical countermeasures in the past, emergencies. during countermeasures medical receive A mechanism to declare an emergency is in place, which allows various levels of government to emergencies. health public during countermeasures medical of procurement rapid for distributors Establish amechanism to allow agreements with national and international manufacturers and/or (GOARN)Network and other partners). involved in emergency response at international level (Global Outbreak and Response Alert Allocate resources to ensure that technical institutions of canbecome networks an part active standards). team medical foreign WHO guidance and continuous training to prepare them for an emergency response (link setting with Provide strengthening capacity programmes to ensure that deployed all staff have the appropriate Relevant documentation Relevant strengthening/challenges need that reas A – – – – – – – – – – – – – – National Disaster Response Plan (page 16), 2010. NDMA, reports. annual NDMA Policy Issuance No Objection Certificate, Flood, 2011. NDMA. Plan. Management Disaster National appropriatewith training, procedures and materials. A comprehensive plan of mobilization of health personnel within the should country developed, be emergency. background and immediate local needs based on the risk assessment of the public health orientationAn package should provided be to foreign health personnel on the local situation, guidelines. received during emergencies. Pakistan could develop or adopt standards of foreign medical team A regulatory mechanism should developed be for licensure and liability of foreign health personnel 59 of IHR Core Capacities of the Islamic Republic of Pakistan RESPOND 60 RESPOND

Joint External Evaluation State Parties should have risk communication capacity which is multi-level and multifaceted real time time real multifaceted and multi-level is which capacity communication risk have should Parties State communications plansneedtobetestedandupdatedasneeded. decision makingareessentialforbuildingtrustbetweenauthorities, populationsandpartners. Emergency mechanisms shouldbeestablished. Inaddition, thetimelyreleaseofinformationandtransparency in and stakeholders inthecountryneedtobeidentified, andfunctionalcoordinationcommunication levels. Disseminatingtheinformationthroughappropriatechannelsisessential. Communicationpartners prevention andcontrolactionthroughcommunity-basedinterventionsatindividual, familyandcommunity voice oftheaffectedpopulation. Communicationsofthiskindpromotetheestablishmentappropriate political andeconomicaspectsassociatedwiththeeventshouldbetaken intoaccount, aswellthe For any communication about risk caused by a specificeventto be effective, thesocial, religious, cultural, the disseminationofinformationtopublicabouthealthrisksandevents, suchasoutbreaksofdiseases. the capacitytocopewithanunfoldingpublichealthemergency. An essentialpartofriskcommunicationis define risks, identifyhazards, assessvulnerabilities andpromotecommunityresilience, therebypromoting Risk communicationsshouldbeamulti-levelandmulti-facetedprocesswhichaimsathelpingstakeholders Introduction Risk communication communities. role ofladyhealthworkers hasbeenessentialindisseminatinghealthmessagesand communicatingwith An existingcommunityengagement structureisutilizedbyotherhealthprogrammes. Since1994, the support fordifferentphases. groups, strategies, messages, activitiesandacoordination mechanismtoprovideadequatecommunication Pakistan in 2006. This plan included pandemic Influenza and outlines communicationobjectives, audience United NationsContingencyPlan, astrategic Avian InfluenzaCommunicationPlan was developedfor Manage Industrial/Technical Disasters (2012)reasonableaddressesriskcommunication. As partofthe Limited riskcommunicationcapacityexistsintheMinistry ofNHSR&C. The NationalContingencyPlanto Pakistan riskcommunicationstrategy encompassingallhazards. Zika, and in some areas for emergencies. These can be used as baseline documents in drafting an all- plans aswellSOPsformajorprogrammes suchasEPI/polio, influenza, Ebola, HIV/AIDS, TBandrecently There isneitheranationalnorprovincialriskcommunication plan. However, there arecommunication activities. times. InPunjab, thehealtheducationunitisessentiallycarryingoutsomeofriskcommunication instance, thereisariskcommunicationstructurefunctioningduringemergenciesbutnosystematother system isinplace. However, there areinformalmechanismsatbothfederal andprovinciallevels. InKPfor Generally, thereislimited capacityintheareaofriskcommunication, andnoformalriskcommunication P T exchange of information, advice and opinion between experts and officials or people who face a threat or or threat a face who people or officials and experts between opinion and advice information, of exchange hazard to their survival, health or economic or social well-being so that they can take informed decisions to to decisions informed take can they that so well-being social or economic or health survival, their to hazard mitigate the effects of the threat or hazard and take protective and preventive action. It includes a mix of of mix a includes It action. preventive and protective take and hazard or threat the of effects the mitigate communication and engagement strategies like media and social media communication, mass awareness awareness mass communication, media social and media like strategies engagement and communication campaigns, health promotion, social mobilization, stakeholder engagement and community engagement. community and engagement stakeholder mobilization, social promotion, health campaigns, arget akistan levelofcapabilities reas that need strengthening/challenges need that reas A practices trengths/best S Score 1: Nocapacity. Noformalgovernmentriskcommunicationarrangement exists. R.5.1 RiskCommunicationSystems(plans, mechanisms, etc.). Indicators andscores actions priority for Recommendations line forcommunicationspersonnel, materialsandactivitiesforemergencies. information needsduringemergenciesinKPandPunjab. These provincesalsohaveadedicatedbudget There arecommunicationspersonnelandgovernmentdepartmentsthatinformallyrespond to public – – – – – – – – – – – – – – – – – – – – – – lady health workers are involved as to surge reach staff out to communities during an emergency. Only emergencies. during risk to communication dedicated staff surge or permanent no are There the provincial risk communication plan. risks. These programme communication plans should reviewed be and considered when drafting programmes such as EPI, dengue, and TB/HIV others have plans drafted and SOPs in communicating Neither anational nor aprovincial risk communication plan is in place. However, major health provincial level should considered be priority. a as the country. The establishment of the risk communication unit at the national level as well as the Building on the existing structure, a formal risk communications system should created be across personnel. communications a Health Education at the Director General Officer as KP to in serve risk of HealthOffice Services There are designated of Public posts Relations and Health Officer Education in Officer Punjab and Punjab. in only emergencies There is adedicated budget line for communications personnel, materials and activities for dissemination. Mechanisms are in place at the federal level and and in KP Punjab to vet messages prior to Punjab. and KP in national and at level emergencies during needs information public There are communications personnel or government that departments informally respond to and messages to address them and share them to with partners ensure message consistency. Establish amechanism for regular collection of rumours and misinformation, finding the methods times. emergency and non-emergency during departments these responsibilitiesof and roles the the different levels of the federal and provincial health structures, and develop guidelines reflecting Develop amechanism to ensure sustained coordination among all communications focal persons in regularly tested and revised as needed. plan encompassing all hazards with SOPs that are endorsed by leadership, shared with partners, Develop aproactive national risk communication plan and provincial risk communication action communication. at the federal and provincial levels with dedicatedwho will formally staff be trained in risk Establish aformal risk communications system by initially creating arisk communication unit

61 of IHR Core Capacities of the Islamic Republic of Pakistan RESPOND 62 RESPOND

Joint External Evaluation identified andtrained; andproceduresforpubliccommunicationareinplace. Score 2: Limitedcapacity. Apubliccommunicationunitorteamexists; governmentspokesperson R.5.3 PublicCommunication. with somepartnersand/orirregularinformationsharing. Score 2: Limitedcapacity. Someadhoccommunicationcoordinationexistssuchasduringmeetings trengths/best practices trengths/best S R.5.2 InternalandP reas that need strengthening/challenges need that reas A practices trengths/best S strengthening/challenges need that reas A – – – – – – – – – – – – – – – – – – – – – – – – – – – – specific audiences. specific such as newspapers, radio, TV, social media, web in order to target communication messages to A communication strategy is needed that proactively reaches out to avariety of media platforms channels. communication preferred and resources information Target audience analyses are required for understanding better of audience language, trusted In Punjab, there is acommittee that reviews, and edits issues publications, clips, etc. TV Advisories for specific diseases are also issued periodically. A seasonal awareness and letter alert is issued tri-annually from NIH. provided. During emergencies, regular media briefings and updates through mass andsocial media are audience. Sindh, and KP Punjab provide information and messages in local languages as needed by the media. the handling for dedicated team communication and spokesperson trained and designated The public health has sector aformalized function to communicate with the public through a stakeholders. Budgeted communication response plans need to developed be with external and partners Exercises should conducted be to test communication and coordination with organizations. partner emergency. an during to release consistent orinformation non-contradictory or regarding which would agency respond strengthening needs emergencies during stakeholders/partners among Coordination/agreement emergency. an during agencies response a formal mechanism in place to coordinate communication among international stakeholders and among civilorganizations, society and with the private during sector an emergency. Punjab has Informal mechanisms exist to coordinate communication with the hospital and health-care sector, forum represented by government, United Nations and partners, international and other NGOs. and internal communication with stakeholders and response agencies through ahealth cluster hasThe country informal mechanisms at both the federal and provincial levels for coordination coordinate for an assessment and then initiate the response. whichafter all i.e. partners, United Nations agencies and international NGOs participate and international community the informs formally event, emergency an during government, federal The artner Communicationandoordination. exist oranongoingsystemwithlimitedunpredictable influenceontheresponse. Score 3: Developedcapacity. Routineandevent-basedsystemsforlisteningrumour management R.5.5 DynamicListeningandRumourManagement. intermediate (provincial/regional)level. the contextofhealthemergencies. Somekey stakeholders inthisdomainareidentifiedatnationaland communication andcommunityengagementareincludedinthenationalriskstrategy in of existingprocesses, programmes, partnersandstakeholders. Socialmobilization, behaviourchange Score 2: R.5.4 CommunicationEngagementwith trengths/best practices trengths/best S strengthening/challenges need that reas A practices trengths/best S – – – – – – – – – – – – – – – – – – – – – – – – All vertical programmes have developed effective IEC components. IEC effective have developed programmes vertical All Communication messages take into account rumours and misinformation from the public. issues; and amethod to addressing them. address rumours and misinformation; ad hoc methods to learn of rumours regarding public health The public health and in KP Punjab sector has aformal communication function to monitor and Health communication messages need to reinforced. be emergencies. A plan is needed to scale up existing community engagement capacities to deployed be during (IEC) materials with members of the target audience as done by vertical programmes. Health need to departments conduct regular testing of information, education and communication at the intermediate (district/provincial) levels, except for lady health workers. There are no social mobilization, health promotion or community engagement functions working emergency). questions, and to receive audience feedback or questions (e.g. and in KP Punjab during the latest group regularly and rapidly changes messages to address audience feedback, misinformation and social mobilization,The health working or promotion engagement community or department communities.with of lady health workers has been essential in disseminating health messages and communicating A community engagement structure is utilized by other health programmes. Since 1994, the role emergencies. during used be to capacity potential surge and volunteers, and experts engagement provides community informationPDMA experienced sharing training or between opportunities emergencies. health at-risk during or populations affected emergencies, regularly work with amedia department or focal person, and reach out to the working groups at the federal and provincial levels that are used for communication during has publicsocial mobilization,The health sector health promotion engagement community or gender biases. messagesto properly, craft consider sociocultural norms and taboos, religious sensitivities and Media research should conducted be to determine messages, as well as arisk perception survey Limited capacity. A community-levelengagementsystemissemi-formedwithmapping Affected Communities. 63 of IHR Core Capacities of the Islamic Republic of Pakistan RESPOND 64 RESPOND

Joint External Evaluation Relevant documentation Relevant strengthening/challenges need that reas A 4

http://www.Polioeradication.org/Portals/0/Document/InfectedCountries/Pakistan/2015-16_NEAP_Pakistan.pdf – – – – – – – – – – National Emergency Action Plan for Polio Eradication, 2015 Polio Plan Eradication, for Action National Emergency forSoPs Prevention and Control of Dengue in Pakistan. Pakistan: Communication Strategy for Routine Immunization, 2015–2018. to address them and share them to with partners ensure message consistency. There is a need to regularly collect rumours and misinformation, to find the methods and messages spreading. misinformation to determine that actions changed behaviour and/or stopped the rumour from There is no evaluation of communication response and ability to address rumours and 4 . States Parties should designate and maintain the core capacities at the international airports and ports and and ports and airports international the at capacities core the maintain and designate should Parties States ports toissueShipSanitation Certificates. No “authorized” seaport, accordingtotheIHRdefinition, hasbeenaddedyettotheIHRlistofauthorized No “designated” PoE, asprescribedbytheIHR, has beendeclaredyetto WHO. vaccination pointsalongtheborder with Afghanistan vaccinating allchildrenagedbelow10 yearsofage. airports, seaports and border crossings vaccinating all travellers in Pakistan. There are also 18 permanent of Polio vaccine bythetimeof departure. UndertheDoCHEthereare17PoE/IHR vaccination pointsat vaccine) orIPV(inactivated poliovirusvaccine) intheprevious4weeksto12monthsreceive adose exporting countriesshouldensurethattravellers whohavenotreceivedadoseofOPV(oral poliovirus Further tothetemporary recommendations ofthepolioIHRemergencycommittee(1March2016), basis asthePoE arepartofthissystem. DoCHE, whichshouldconsiderstandardizedreportingtofeedthenationalsurveillancesystemonaregular of international concern (IHR Articles 22 et 4). They transmit data regarding their routine activities to the The PoE canreachouttotheIHRNFPthroughDoCHEincaseofanypotentialpublichealthemergency the Directorate ofCentral HealthEstablishments(DoCHE)under theauthorityofMinistryNHSR&C. The public health representatives at PoE are the “competent authority” as per the IHR. They respond to Wagah) andthreeinternationalseaports(BinQasim, Gawadar, Karachi andKeemari). Peshawar, QuettaandSialkot), sixgroundcrossings(Chaman, Khokarapar, Sost, Taftan, Thurkum and Pakistan encompasseseightinternationalairports(Faisalabad, Islamabad, Karachi, Lahore, Multan, south-west andthePeople’s RepublicofChinainthefarnorth-east. by Indiatotheeast, theIslamicRepublicof Afghanistan tothewest, theIslamic RepublicofIran tothe Pakistan hasa1046kmcoastlinealongthe Arabian Seaand theGulfofOmaninsouthandisbordered P T variety ofpublichealthrisks. ground crossings in order to be able to implement specific public health measures required to manage a required tomaintainthecorecapacitiesatdesignatedinternationalairportsandportsdesignate effective applicationofhealthmeasurestopreventinternationalspreaddiseases. StatesParties are All IHRcorecapacities and potential hazards applytopointsofentry(PoE) and thisis a key areaforthe Introduction Points of entry OTHER designate ground crossings which implement specific public health measures required to manage a variety variety a manage to required measures health public specific implement which crossings ground designate of public health risks. health public of arget akistan levelofcapabilities 65 of IHR Core Capacities of the Islamic Republic of Pakistan OTHER 66 OTHER

Joint External Evaluation Indicators andscores Recommendations forpriorityactions reas that need strengthening/challenges need that reas A practices trengths/best S and premises. diagnostic facilities for the prompt assessmentand care of ill travellers and withadequatestaff, equipment Score 2: Limitedcapacity. DesignatedPoEs haveaccesstoappropriatemedicalservicesincluding P oE.1 Routinecapacitiesare establishedatP – – – – – – – – – – – – – – – – – – – – – – – – – – water, liquid and solid waste management and vector control. vector and management water, waste solid and liquid Deficiencies in terms of inspection and supervision of programmes relate safety,to food potable partners. development and donors government, the by provisions budgetary by followed A comprehensive procurement plan should developed be for personnel and the logistics needs, inadequate. or absent either are Quarantine area and ambulances for the transport of ill travellers to appropriate medical facilities requirement, and their technology and logistics needs followed by aprocurement plan. Detailed and comprehensive assessments of all should POEs conducted be to determine personnel personnel covering especially civil aviation and the maritime aspects areas. A continuing training programme needs to customized be and adapted to the specific needs of the facilities. transport and linkages referral equipment, diagnostic availability, facilities, quarantine All need strengthening POEs in terms of manpower, their skill development, appropriate space Certificates. Ship Sanitation EventsImportant and Development Monthly Form, Monthly of Report Principal Activities, and Health, and Origin of Declaration Personal Tracking Clearance Certificate, Health Handlers, Form, Fitness to Fly, Restaurant Canteen/ Check-Up, Food-Outlet Medical Examination for Report Food ofPart the General Declaration of Health, the Death Certificate, the Medical Certificate of situation at the PoE using documents like: the International Certificate of Vaccination, the Health epidemiological the regarding relevantinformation Consistent provides management data recommendations.committee emergency IHR the line in with vaccination coverage national polio Full mobilizationcomplements aviation and primary authority atcare airports units for Pakistani seafarers at seaports. travellers. This is reinforced capacity by the presence of medical emergency units under the civil Overall, they include preliminary diagnostic facilities for the prompt assessment and care of ill a fewWith exceptions, alimited range of the medical are services available at PoE in Pakistan. IHR. current provisions are related to the International Regulations, Sanitary 1951, the predecessor of the Update the Pakistan Aircraft Health Rules, 1970 and the Pakistan Health Port Rules, 1974 whose other relevant stakeholders in order to involve them more in public health issues. Set up and enhance mechanisms of collaboration and coordination, at central and local level, with Implement the authorization process of port and designation points of entry as per the IHR. Ensure that PoEs constitute an integral of the national part surveillance system. oE. sectors andservicesatPoE developedanddisseminatedtoallkey stakeholders. to theseemergenciesatPoE, integrated withotherpublichealthresponseplans, coveringallrelevant Score 2: Limitedcapacity. Anationalpublichealthemergencycontingencyplanisinplaceforresponding P Relevant documentation Relevant strengthening/challenges need that reas A practices trengths/best S oE.2 ffectivePublicHealthResponseat – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – of the Ministry of National and Research. Security Food of Plant Protection or the Animal Quarantine both Department, of which are under the authority There is no channel of communication or collaboration with privileged like partners the Department Plan. shouldPOEs brought be into the ambit of the National Emergency Preparedness and Response should triggered be with aview to eradication. outbreak of vector-borne disease or the detection of exotic species, vector an immediate response borne diseases. This will proper support decision-making on control vector methods. In of case an A surveillance plan should established be targeting local and potential species vector and vector- control. vector and management, water, waste solid potable and liquid safety, food There is aneed to review the adequacy of inspection and supervision of programmes related to or exit controls for arriving and departing travellers, and isolation rooms. transport of ill travellers to appropriate medical facilities, PPE for staff, regarding SoPs the entry The adequacy of public health at PoE services should reviewed, be including: ambulances for the and progress and for joint actionas and when required. regularly and periodically with the concerned cross-border agencies for joint reviews of the status Similarly, institutional arrangements and culture should developed be to coordinate and liaise should ultimately link up with the national surveillance system. shouldPOEs equippedbe to generate digital reporting (through a customized software) which IHR. of framework There is need to enhance cross-border collaboration with neighbouring countries under the including the existence of isolation rooms and referral to designated health facilities. Clear areSoPs lacking regarding or exitthe controls entry for arriving and departing travellers There is of ashortage appropriate personal and protective equipment. Civil Aviation Organization, Annexes 6, 9, 11 and 14. This process is in progress at seaports. international concern. It is in compliance with the relevant articles in the IHR and the International Thisairports. plan describes the measures to adopted be during apublic health emergency of international plans at emergency the within plan isembedded emergency health public The dispensaries limited with capacities. enabling them to comply with IHR regulations for having air and sea human ports resources/ Technical and administrative matters of central health establishments should reorganized, be Adequate space should made be available for medical facilities and technical at PoE. staff Pakistan Aircraft Health Rules, 1970. of theDraft Pakistan Public Health (Surveillance and Response) Act,2010. oints ofEntry. 67 of IHR Core Capacities of the Islamic Republic of Pakistan OTHER 68 OTHER

Joint External Evaluation – – – – – – – – – – – – – – Points for of SoPs Entry Ebola. Brief. DCHE PointsWHO of Assessment Reports. Entry Plans. Contingency Airport Map of Points of Entry, Pakistan, 2013. Civil Aviation AuthorityOrdinance, 1960. Pakistan Health Port Rules, 1974. State Parties should have the surveillance and response capacity for chemical risk or events. It requires requires It events. or risk chemical for capacity response and surveillance the have should Parties State Recommendations for priority actions Recommendations for priorityactions and unpredictablesources. of theneedtoprotectenvironmentandpopulationhealth fromthechemicalhazardsofknown, diffuse tape. As Pakistan embraces industrialization andcommonsecurity treats, there is growing acknowledgement safety lawsandregulationsonindustry, ascourtsusuallyviewsuchcasesunwarranted andasignofred regulations atprovinciallevel. This isreportedtohavehamperedEPA’s abilityto enforceenvironmental There isalackofawareness inthejudiciaryofpublichealthimpactandbenefitenvironmental EDH Directorate hasbeenestablished inthisregard. disasters. InPunjab, EPA hasdrafted rulestodealwithhazardoussubstances, hospitalwaste, etc. andan level, EPA and NDMA prepared a National Contingency Plan in 2010 to manage industrial and chemical Currently, EPA has no baselinedataorpropersystem to dealwithhazardoussubstances. At national deliberate releases. emergency responders/services andhealth sectors to rapidly detect and containaccidental, natural or is nointegrated surveillanceorearlyalertprotocolbetweenrelevant industry, regulatoryauthorities, of sensitiveindustrialfacilities, andlimited, leftoverstockpilesandchemicalwastes aread hoc andthere population healthandtheenvironmentfromrisksofuncontainedchemicalevents. Regulatoryinspections frameworks areinplacetodealwithoccupationalhealthandwell-being, orprovide protectionofwider utilizing infrastructure andexperienceavailable inthecountry. Nocohesivelegislativeandorganizational However, asystematicapproach hasyettobeadoptedinthemanagementofchemicalsectorsby concerning hazardouschemicalsandsafety. including significantchemicalevents. Pakistan has ratified relevant globaltreatiesandconventions environment whileNDMAistheleadauthoritytocoordinatemulti-agencyresponsesmajordisasters Pakistan’s EnvironmentalProtection Agency (EPA) isresponsiblefortheprotectionandwell-beingof research sectorsandhavethecapacitytodetectenvironmentalpresenceoftypicalchemicalsubstances. agrochemicals in its large agriculture sector. Laboratory facilities exist within academic and government In Pakistan, concernsaboutchemicalrisksandsafetyhavetraditionally beencentred ontheuseof P T transportation, safedisposalandhealthprotection. communication andcollaboration amongthesectorsresponsibleforchemicalsafety, industries, planning, should thereforehavethesurveillanceandresponsecapacityforchemicalriskorevents. Itrequireseffective infrastructure unless coordinated multi-agency response is mobilizedin a timely manner. Stateparties Uncontrolled chemicaleventscanconstituteasignificantthreattopublichealth, servicesectorsand Introduction eventsChemical effective communication and collaboration among the sectors responsible for chemical safety, industries, industries, safety, chemical for responsible sectors the among collaboration and communication effective planning, transportation, waste disposal, environment, and public health protection. health public and environment, disposal, waste transportation, planning, arget akistan levelofcapabilities – – chemicals life sector; of chemicals cycle and waste; threats security involving chemicals; multi- Review prevailing regulations inand thescope context ofto theiraddress: efficacy theexpanding

69 of IHR Core Capacities of the Islamic Republic of Pakistan OTHER 70 OTHER

Joint External Evaluation reas that need strengthening/challenges need that reas A practices trengths/best S chemical events, intoxication andpoisoningareavailable. Score 2: Limitedcapacity. Guidelines or manualsonthe surveillance, assessment andmanagementof events oremergencies. CE.1 Mechanismsare established and functioningfordetectingresponding tochemical Indicators andscores – – – – – – – – – – – – – – – – – – – – – – – – – – – – partner organizations. organizations. partner the “competent authority” to deal withof all chemicals aspects and coordination with all relevant integrated with wider public health surveillance. This will benefitfrom assigning an as authority events of facilities that use chemicals, not just during the inspection and enforcement period, but Relevant authorities need to map and implement routine surveillance and monitoring of chemical This could clearly include EPA on the Provincial Multisectoral IHR Task Force/Committee. approachagency to develop practicesgood in proactively managing chemical threats. security with those responsible for industry, trade, regulation, agriculture, and planning to ensure amulti- There is aneed for participation active of authorities of public health and emergency responders ratified. have been Relevant key conventions/agreements international chemical A National Poison Control Centre is established at Jinnah Postgraduate Medical Centre, Karachi. Chemical assessment safety focusing surveys on agriculture have been carried out. isavailable hospitals. poisoning at chemical handle to unit emergency An and Industrial Research, NARC, and provincial facilities. is available capacity Laboratory for the analysis of chemicals at the Pakistan Council of Scientific events. isNDMA mandated to provide coordinated response to significant industrial accident/chemical Coordinate with industrial associations to collect and share relevant data. emergency. profiling, vulnerabilityand templates assessments, riskfor communication duringfor use an Develop adatabase and shared-information repository/inventory for chemical stockpiles, risk development. systems health detection, toxicology, alerts, risk assessment and health protection –integrated with resilient Strengthen human and financial resources to enable routine chemicalsafety, surveillance, waste, ship-breaking operations, disposal mechanisms of obsolete chemicals, etc.). the prevention and control of chemical incidents/emergencies (including those related to imported partnership with relevant industry, regulators, emergency health for services chemical safety, and Review, update, develop, strengthen and operationalize public health protection plans in standards. quality environmental standards/national delivery relevant Compileminimum implement and service regulations. Train nominated and lawyers judges on the public health impactand benefit of environmental implementation at all three administrative tiers (federal, provincial and district). cohesive national regulations associated guidance with statutory outlining responsibilities and of development the to lead should This services. health i.e. coordination, emergency agency Score 2: Limitedcapacity. Nationalpolicies, plansorlegislationforchemicaleventsurveillancealert CE.2 Enablingenvironment isinplaceformanagementofchemicalEvents. 5 strengthening/challenges need that reas A practices trengths/best S and responseexist.

Elements ofalertinclude SOPsforcoverage, criteriaofwhenandhowtoalert, duty rostersetc. – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – qualitative and quantitative toxicology. quantitative and qualitative toxicology. This could include the development of laboratory facilities capable of performing There is an urgent need for training of on chemical health-care staff risk assessment and medical to provide rapid identification of acute, fast evolving and protracted chemical events. environmental including surveillance in place those for drinking network, water monitoring, quality facilitiesLab at public, private and research should sectors able be to link with the national know-how.and level to handle chemically contaminated or poisoned patients, resourced logistics with necessary Consideration should given be to have at least one hospital as areference serve facility at provincial learnt. The audit/evaluation system should include exercises/responses to chemical events and lessons practices in chemical management. sector Consistent law enforcement should take place at all three levels of the to country ensure good contingency plans developed with input from public health professionals. A database should set be up on high tonnage industrial chemicals and stockpiles, and risk-based involvedsectors in chemicals, surveillance, emergency response and health services. A coordination mechanism should established be for systematic information sharing the between A National Poison Control Centre is operational at Jinnah Postgraduate Medical Centre in Karachi. action planAn is available for public health in the safety event of chemical incidents/emergencies. authority. A strategic plan is established for industrial chemical formulated safety by the plant protection management. disaster National coordinating bodies exist for pesticide management, safety environment protection and prioritized. Awareness, control and monitoring of the use of chemicals in the agricultural should sector be established. and management waste developed for options safe and reviewed, be of and waste security The safety disposal systems and facilities for hazardous chemicals need to present potentially significant risks to public health. inventoryAn and risk profile shouldbe made of chemicalstockpiles and industries that could hazards. health public and environmental contemporary and emerging economic activities such as ship breaking with regard to chemical, Monitoring of consumer should products put be in place (e.g. and goods) foodstuffs and of PPE. and management of chemical events, intoxication and mass-poisoning, decontamination, and Guidelines or manuals are needed on surveillance, environmental public health risk assessment 5

71 of IHR Core Capacities of the Islamic Republic of Pakistan OTHER 72 OTHER

Joint External Evaluation Relevant documentation Relevant – – – – – – – – – – – – – – National Poison Control Centre at Jinnah Postgraduate Medical Centre Karachi. Islamabad. Hospital Security Social JEEIHR Toolreport. self-assessments country Pakistan National Disaster Management Authority, www.ndma.gov.pk/site. http://environment.gov.pk/. Agency, Protection Environmental Pakistan industry. on regulations regulations at provincial levels, which will enable EPAs to enforce environmental laws safety and Judiciary awareness needs to created be of the public health impactand benefit of environmental of toxicology systems alert with public health authorities and hospitals. Karachi should exploited be and expanded to other provincial levels. This could entail establishment The telephone-based/online toxicology of the service National advisory Poison Control Centre, manage patientsofradiation emergencies. State Parties should have surveillance and response capacity for radio-nuclear hazards/events/emergencies. hazards/events/emergencies. radio-nuclear for capacity response and surveillance have should Parties State 6 practices trengths/best S Score 5: Sustainablecapacity. Amechanismisinplacetoaccess radiological andnuclearemergencies. RE.1 Mechanismsare establishedandfunctioningfordetectingresponding to Indicators andscores Recommendations forpriorityactions standards andguidancearecloselyfollowedregularlyevaluated. with adequateresources. A coordinationmechanismisinplacewithrelevant stakeholders, andinternational facilities totreatcontaminatedindividualsorvictimsofradiation emergenciesareenlisted andavailable for surveillance, laboratory analysis, hazardassessmentandtheconductofexercises ordrills. Medical Emergencies. The emergencyplansarerevisedandupdatedregularlyadequateresourcesensured regulatory authorityisavailable forEPR, e.g. theRegulationsonManagementofNuclearorRadiological Disaster Management Authority Planandaddressesallradio-nuclear emergencies. Adequate legislation/ reports thatarereviewedatPNRA. The NuclearEmergencyManagementSystemfallundertheNational assessments ofmedicalradiation facilities, andthenuclearradiation facilitiesprovideannualsafety surveillance, preparednessandresponse. This authorityhasadequateavailable resources, performssafety The Pakistan NuclearRegulatory Authority (PNRA)isthedesignatedinstituteforradiation safety, P T Radiation emergencies It requires effective communication and collaboration among the sectors responsible for radio-nuclear radio-nuclear for responsible sectors the among collaboration and communication effective requires It management.

arget akistan levelofcapabilities Agreements, arrangements andmechanisms existtoaccessthesecapacitiesinrelevant collaborating institutions in-countryorinothercountries. – – – – – – – – – – facilities provide annual that are reports reviewed safety at PNRA. radiation and nuclear The radiationfacilities. medical of assessment safety performs PNRA availableadequate resources. the designatedPNRA, institute for radiation safety, surveillance, preparedness and response, has programme and increased use of radiation in medical, industrial and other sectors. Allocate additional human and financial resources to embrace theexpansion of the nuclearpower point to coordinate and communicate with the Ministry of NHSR&C and the IHR NFP. National authorities responsible for radiological and nuclear events to identifyadesignated focal international of concern. emergency health public a may constitute that risks authorities and human health surveillance units about urgent radiological events and potential Establish and maintain systematic information exchange radiological between competent 6 healthfacilitieswithcapacityto 73 of IHR Core Capacities of the Islamic Republic of Pakistan OTHER 74 OTHER

Joint External Evaluation the requestingofinternationalassistance(asneeded)andnotification. Score 5: Sustainablecapacity. Radiationemergencyresponsedrillsarecarriedoutregularly, including RE.2 nablingenvironment isinplaceformanagementofRadiationEmergencies. reas that need strengthening/challenges need that reas A Relevant documentation Relevant strengthening/challenges need that reas A practices trengths/best S 2. 1. – – – – – – – – 3. 4. – – – – – – – –

The International Atomic Energy Agency evaluation and certification (findings). certification evaluation and International Agency Atomic Energy The nuclear power programme and increased use of radiation in medical, industrial and other sectors. Allocation of additional human and financial resources are required due expansionto of the etc.). laboratory reference services, likeemergency environment, health, sectors Coordination with relevant stakeholders is in place (national and subnational levels of all relevant resources. adequate of availability and responsibilities, public communication, populations, decontamination management affected of and roles delineation of clear with SOPs has system management emergency nuclear A available. Adequate legislation and astrategic plan on radiation protection required for radiation is safety coordination and communication with the Ministry of NHSR&C and the IHR NFP. National authorities responsible for radiological and nuclear events should identified be for international of concern. emergency health public a may constitute that risks authorities and human health surveillance units about urgent radiological events and potential Mechanism are needed for systematic information exchange radiological between competent for waste management, and regularly monitor them. has authority toPNRA assess facilities, issue and revoke licenses, set standards and requirements updated following exercises or drills. Authority Plan, manages nuclear and other radiological emergencies; the Plan is revised and Management National Disaster the of part System, Management Emergency Nuclear The Reports of exercisesReports and drills. Legislation mentioned (copies).Legislation mentioned Nuclear Emergency Management System Plan (NDMA Plan). Plan System (NDMA Management Emergency Nuclear trengths/best practices trengths/best S the healthsecurityneedsof21stcentury. national importanceexistbutare3–4decadesold. These needradical revamping toalign withandmeet quarantine, detection, andresponsetopublichealththreats. Legislativeactsto addressthesetwoPoEs of The airportandseaportinKarachi havemoderate levelsofassets andcapacitiestoshouldersurveillance, physicians. There isalsoneedforadditionalladyhealthworkers. to hirepublichealthprofessionalsinaquickandefficientmanner. Presently, thereisashortageof4000 is slow. The multidisciplinary natureofthepublichealthworkforcehasoutgrownabilitysystem resource departmentandtheprovincereliesonantiquatedpublicservicescommissionsystem, which existing set-up of training is insufficient. The training academyis virtuallynon-existent. There is nohuman In Sindh, theprovincialcellsareunder-staffed. There arenosurveillancemonitoringofficers. Also, the public healthapproachtoimplementationofcare, food, water safetyand zoonosis management. of preventionandcontrolactivitiesversusmerecurative health-careisneeded–thusintroducing astronger health security-relatedcadres. Advocating betterunderstandingonthebenefitsand long-termcostsaving and biosecurity, andEPRshowlimitedcapacities. A workforcestrategy is underformulationto support assessment indicatorsfordiseasesurveillance, immunization, zoonosis, foodsafety, laboratory, biosafety Capacities andfunctionsinprovinciallyrelevant JEEactionareasrange fromlowtomoderate. Key education andagricultureasitsthreemajoreconomicincome-generating activities. and economichubamajorseaport. immunization, The provincehasanindustrializedeconomy withmanufacturing, biosecurity, and largest provincebypopulation. The provincialcapitalanditslargestcityisKarachi –thecountry’s financial biosafety Situated inthesouth-easternpartofPakistanlaboratory, withthe Arabian Seatothesouth, Sindhisthesecond Safety, food zoonosis, priorities. top assessed: their be areas to Technical province each by identified areas Sindh technical specific on focus reports Provincial Note: regions. sub-missions to the four major provinces and a separate session to assess the other four semi-autonomous emphasis was givenduringthemissiontocaptureprovincialcapabilities. This was achievedbyaseriesof the federal system of Government specified by the Constitution of the Islamic Republic of Pakistan, special Due tothehighlydevolvednatureoforganizingcapabilitiesnecessaryachieveIHRcompliancein federating provincesand on areas Reports surveillance, workforce development, EOC, risk communication, PoE, chemical hazards. chemical PoE, communication, risk EOC, development, workforce surveillance, – – – – – – – – responsive outbreak investigations conducted canbe in the of case human zoonotic diseases. A system for monitoring endemic zoonotic diseases and outbreaks among livestock and exists poultry) and care hospitals tertiary in the private sector. (cattle, sector isavailable veterinary the in capacity surveillance and epidemiological Laboratory, A human resources strategy and aseparate public health management cadre are in place. levels. provincial and There is awillingness to develop One Health approaches across specialties federal and between 75 of IHR Core Capacities of the Islamic Republic of Pakistan OTHER 76 OTHER

Joint External Evaluation reas that need strengthening/challenges strengthening/challenges need that reas A Recommendations for priority actions Recommendations forpriorityactions – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – system, includingsystem, for laboratories. Ensure workforce development for disease surveillance and response at all levels of the health Establish apublic health reference laboratory at the provincial level with links to the NIH laboratory. with the Environmental Protection for Agency chemical hazards. Urgently improve to systematically capacity prevent and respond to poisonings, and to coordinate Conduct ahazard analysis and develop and execute provincial multi-hazard EPR plans. provinces. of areas slums/rural/desert urban in especially coverage and access immunization Improve Health approach and link with PoE, One Health and the national level. diseases within the and human between and animal health for zoonoses sectors under the One multisectoral coordination mechanisms for surveillance, and response for priority reporting, Establish disease active surveillance with peripheral coverage: strengthen and establish formal implementation through notifying the IHR Task Force with specific terms of reference. Strengthen multisectoral coordination to address public health threats and IHR/GHSA regulationsimplementation safety and monitoring. food of Create/update legal instruments for One Health approaches to zoonoses, and for effective arsenic in ground water as well as methanol poisoning and drug overdoses. Major challenges continue regarding environmental exposure to pesticides and chemical waste, exists. surveillance resistance antimicrobial No Public health laboratory in human capacity health is weak or non-existent. Awareness is low in the health on the current sector situation of zoonotic health threats. Reporting of zoonotic livestock outbreaks routinely remains within the veterinary sector. TB). bovine rabies, Many zoonotic infections remain endemic and cause frequent outbreaks (anthrax, brucellosis, Legislative to address key the acts two PoEs need to updated be at the federal level. A legislative covers Act the Karachi Trust. Port Local veterinary vaccine production enables rapid tailoring as required to local needs. Province. Sindh Electronic DHIS syndromic surveillance and ahealth management system are available in the A disease surveillance unit with exists competent FELTP-trained at the Health staff Directorate. BSL-3 played varying degreesofadherence tobiosafetyandbiosecurity. Onelaboratory designedtooperate at A priorityactionareaforPunjabislaboratory/biosecurity/biosafety capacity. The laboratories visiteddis- health sectorintheGovernmentduetolackofcareerladders andincentives. pursue careers as instructors and academicians in public and private institutions and not in the public in publichealththroughtheirMastersPublicHealthprogrammes. However, mostofthetrained students demic institutionssuchastheUniversityofHealthSciences andInstituteofPublicHealthprovidetraining training programmes attheprovincialanddistrictleveltoenhancediseasesurveillanceresponse. Aca- In Punjab, thereisalsoaneedfortraining frontlinepublichealthworkers, throughFELTP andotherrelevant and logistics, healthinformatics, etc. eases andsurveillance, vectorcontrol, healthsystemsstrengthening, internationalcoordination, operations relevant, wellqualifiedexpertstoleadtherespective technicalareasofmanagement, communicabledis- demands ofthe21stcentury, adoptingastructure thatwillimprovefunctioningandoperation byhiring Despite thisrelativelygoodpositioning, theprovincialhealthdepartmentisrestructuringtomeet and appropriate. priate staffingatalllevelsandacrossdisciplinesusingexistingsourcessuchastheFELTP, wherepossible system supportedbyatieredofpublichealthlaboratories. Stepsshouldbetaken toensureappro- province shouldincreaseitscapacityandestablishastronggenericpublichealthsurveillancereporting some disease-specificsurveillancesystemsarefunctioningwell(e.g. AFP, measles, Dengue, ILI/SARI), the ease surveillancesystemsarecriticalfordetectionandresponsecoordinationofinfectiousdiseases. While staffing oftheprovincialdiseasesurveillanceandresponsesystem, whichisyetfunctioning. Effectivedis- to moderate progressinmeetingIHRstandards. Additionally, therewerequestionsabouttheappropriate Technical areas with primarily national responsibility such as chemical hazards and PoEs showed minimal whether otherfactorssuchashigherfundingcontributedtoPunjab’s betterperformance. certainly beenhelpedbygoodgovernance, theteamwereunable, inthetimeavailable, todetermine provinces althoughsubstantialstrengtheningandimprovementarestillnecessary. While thishasalmost multisectoral coordination, andimmunizationwerebetteraddressedincomparisonwiththeotherthree health securityareaslike diseasesurveillance, reporting, zoonosis, preparedness, response, IHRadvocacy, province alsoprovidesin-countrybestpractices forotherprovinces/areas/territoriestoreplicate. Key IHR technical areasthathaveprovincialimplications, rolesandresponsibilities. With capacityinmostareas, the During thisassessment, PunjabProvincedemonstrated themostadvanced capacityintermsoftheJEE regional cultural, historic, andeconomiccentre. Pakistan, representing39.2%oflarge-scaleand70%small-scalemanufacturing. Lahoreisamajor and cottonbeingtheprincipalcrops. Sinceindependence, itremainsthemostindustrializedprovinceof capital andlargestcityisLahore. Agriculture isthechiefsourceofincomeandemployment, withwheat square miles) and a population of 9.14 million in 2011, 56% of country›s total population. Its provincial 7 - labo hazards), (chemical environment Punjab isthemostpopulousofallprovinces/areasPakistan. km Ithasanareaof205 344 communication, risk and coordination IHR assessed: areas Technical Punjab ratory, biosafety and biosecurity, surveillance, reporting, workforce development, zoonosis, PoEs, EOC PoEs, zoonosis, development, workforce reporting, surveillance, biosecurity, and biosafety ratory,

The externalteamdidnothavetheopportunity toverifydesignandoperational qualitiesrequiredforaBSL-3laboratory. 7 andsixBSL-2laboratories, althoughatleastoneisstill tobecommissioned. 2 (79 284 (79 284 77 of IHR Core Capacities of the Islamic Republic of Pakistan OTHER 78 OTHER

Joint External Evaluation Ebola, Zika. sectors worktogetherwhenfacedwithanimminentthreat/activeoutbreak, e.g. dengue, polio, pandemics, Although aformallyestablishedmultisectoral mechanismforIHRcoordinationdoesnotexist, therelevant certified foodlaboratories forwhichproficiencytestingisconductedincollaboration with FAO. currently assiststhelivestockdepartmentwithdiagnosticsofseveral animaldiseases. There aretwoISO laboratory isalsounderestablishmentandexpectedtobeoperational withinmonths. PunjabUniversity laboratory, althoughitdoesnotperformafullrange ofprioritydiseasetesting. A provincialfoodsafety that isduetobecommissionedimminently. This facilityisbeingconsideredastheprovincialreference The InstituteofPublicHealthinLahorehasrefurbishedanewlaboratory, designedtooperate atBSL-3, offered. tee. PunjabUniversityhasinternalregulationsunderwhicha2-credithourcourseonbiosafety/securityis tions conductingresearch/diagnosticsarerequiredtohaveanInstitutionalBioriskManagementCommit- method ofmaintaininganinventoryhigh-riskpathogens. Punjabhasrelevant legislationandallinstitu- The ShaukatKhanumMemorialCancerHospitalwas theonlylaboratory visitedthathadasystematic trengths/best practices trengths/best S – – – – – – – – – – – – – – – – – – – – – – – – – – A provincial IHR focal point has been designated. eventAn management system is in place. Multisectoral IHR coordination is triggered by an event. testing. proficiency industry, and international bodies; ISO certified labs two andseveral others participate in FAO lab and Public Health. It also has astrong research focus with collaboration with local government, UVAS incorporates training on One Health in their curriculum an and MPhil offers in Epidemiology disease. mouth on diagnostics, research, and training with several on brucellosis, projects CCHF and foot and UVAS faculty have ties good with the livestock as departments andthey food collaborate safety Incentives (hardship area allowances) are available to retain the existing health workforce. A human resources strategy and aseparate public health management cadre is in place. A well developed human resource Information System is in place. One BSL-3 and six BSL-2 laboratories are functional in the province. riskA good communication mechanism also for exists public health professionals. exists. programme response and surveillance influenza avian strong A otherwise with required actions. are SOPS in place. The dashboard also as amonitoring serves and evaluation tool highlighting compliance or phones. cell android immunization and polio eradication with dashboard/electric records are accessible through Real-time surveillance, and reporting assets capacities under indicator-based surveillance for Recommendations for priority actions Recommendations forpriorityactions strengthening/challenges need that reas A – – – – – – – – – – – – – – – – – – – – – – – – – – – – of embracing aOne Health approach. Promote with district coordination IHR advocacy for IHR/GHSA offices in general, and thebenefits Committee. ,andSupport develop terms of reference for amultisectoral IHR Implementation Task Force/ improve biosafety with increased access and training in the use of PPEs. Develop and implement abiosecurity and biosafety programme following the national model, and which poses amajor public threat. safety capacities,safety from transportation to storage to disposal, are lacking or extremely limited, industrialized and agriculture-dependent province use withof heavy pesticides. Current chemical Ensure as atop adequate priority and appropriate response to chemical hazards in this highly disease surveillance at all levels of the health system including, but not limited to, FELTP. Ensure consistent allocation/recruitment of appropriate across all staff disciplines for effective structures, and incentives for atrained workforce. Develop health workforce planning on asystematic basis, using estimated future needs and career disease as it prevalent is very in livestock. at the Institute of Public Health, including BSL-3 with Mycobacterium bovis as azoonotic priority Develop aprovincial public health reference lab by strengthening at the capacity existing laboratory an IHRNotify Task Force at provincial level to coordinate with all stakeholders under IHR. notifiable diseases; the latter shouldbe updated on a regular basis. outbreaks and emergency response under the One Health approach based on the provincial list of Strengthen and build further upon existing coordination mechanisms for disease active surveillance, authorities. health and security laboratories throughout the province; this information should shared be with the national public Establish acomprehensive inventory for high-risk pathogens in both human and veterinary diseases. notifiable of A coordinated disease surveillance and response mechanism based on is updated necessary list seasons. peak and alert during undertaken are activities unit does exist within the provincial health department, and health education and communication No overall risk food safety communication strategy currently although exists ahealth education testing. The provincial public health reference laboratory does afull not perform range of disease priority pathogens. high-risk of inventory an maintaining of method systematic The Shaukat Khanum Memorial Cancer Hospital was the only laboratory visited that had a 79 of IHR Core Capacities of the Islamic Republic of Pakistan OTHER 80 OTHER

Joint External Evaluation nostic laboratories toexploreresearch opportunities. functional laboratory but no funding toundertake research. Itwould be interested in working with diag- also offereditssupporttoKPinthisregard. Onarelatednote, KPUniversityhasagroupofPhDsand to establishaprovincialreferencelaboratory thatiswellsupportedbytheprovincialgovernment. NIHhas enrolled asundergraduates. The districtlaboratories performverylimitedtesting. A strongdesireprevails ISO 9001:2000butnoneto15189. There arefewpathologistsintheprovince. About 120scientistsare The fourteachinghospitalsinKPhavenointeraction. Two medicaltestinglaboratories areaccreditedto Afghan citizenswhocrossthebordertoseekbetterhealthcare. this isnotaccessibletootherdiseasesbecauseitfundedfor TB only. The laboratories inKPoftenservice formance oftestingbyEQAS, re-testingandfieldvisits. A TBlaboratory appliesBSL-3practices; however, TB laboratories have an active training programme for GeneXpert and microscopy, and monitor the per vincial TB laboratory performsafullrange of TB microscopy, culture, sensitivityaswellmoleculartesting. in KP is an excellent example of a tiered approach to laboratory testing, surveillance and control. The pro- rity. Onelaboratory inthe provincehasabiosafetyregulationbutnoofficers. The TBprogramme As withotherprovinces, thereisabasicapproachtobiosafetybutonlyrudimentarybiosecu- attention. A risk/hazardanalysishasbeencompletedandamulti-hazardsEPRplanis inplace. Since KPundergoesfrequentflashfloodsinthemonsoonseason, EPRcapacitieshavegarneredsignificant lic health. Similarly, acareerstructureforpublichealthprofessionalsincludingFELTP graduates islacking. also being formulated although it currently focuses disproportionately on clinical care cadres and not pub- a provincialstrategy forIHRimplementationisunderdevelopment. A workforcedevelopmentstrategy is functioning, andoperations. Progresswas showninIHRadvocacy, legislationonfoodsafetyisinplace, and safety, surveillance, reporting, immunization, preparednessandresponse)showedconsiderable progress, Assessment oftechnicalareasthathaveprimarilyprovincialrolesandresponsibilities(e.g. zoonosis, food large numbersof Afghan refugeesaswellthoseinternallydisplacedbyepisodesofconflictintheregion. The provinceisstillreelingfromthemassiveearthquake in2005, severeflashfloodsin2010–2011and the country’s economyandishometoapproximately 26millionpeople(12%ofthecounty’s population). sur international borderwith Afghanistan connectedthroughthehistoricKhyberPass.laboratory, Itcontributes10.5%of immunization, the north-westernpartofPakistan. The provincialcapitalandthelargestcityisPeshawar. KPsharesan communication, and Khyber Pakhtunkhwa (KP)isthethirdlargestprovinceofPakistan bysizeandeconomy; itislocatedin coordination IHR zoonosis, assessed: areas Technical Khyber Pakhtunkhwa trengths/best practices trengths/best S veillance, preparedness, risk communication. risk preparedness, veillance, – – – – – – – – informal coordination committee. There is event-based collaboration animal between and public health as well sectors as an A comprehensive programme for avian influenza exists. authorities, are in place.security RRTs, for medical countermeasures and personnel deployment, and for linking public health with A hazard analysis has been undertaken and an EPR plan is in place. Measures for deployment of as abase from which to create additional synergies. Experience gained from EPR, in particular multisectoral collaboration and coordination, canserve - - Recommendations for priority actions Recommendations forpriorityactions strengthening/challenges need that reas A – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – Formulate and implement arisk-based mechanism. food safety a laboratory at province network and district level. Establish reference a KP laboratory with the capabilities to test for pathogens,priority and develop level. provinces, and places biosafety regulations andin officers all major laboratories at the provincial Develop and implement anational biosecurity and biosafety programme that transcends all Ensure interruption of wild poliovirus transmission in 2016. Address gaps in immunization coverage among vulnerable groups Introduce simulation exercises and drills on aregular basis to test EPR plans. Formulate arisk communication strategy. and related career structures. Ensure that the workforce development strategy includes sufficient focus on public healthcadres under the One Health approach. human diseases within and animal health,response for priority and between health for zoonoses and reporting, surveillance, for mechanisms coordination multisectoral formal establishing Ensure integrated active disease surveillance with peripheral coverage by strengthening and IHR Task Force at provincial level. outbreaks and emergency response under aOne Health approach and in this an context notify Establish formal intersectoral coordination mechanisms for IHR,disease surveillance, and groups. hard-to-access mobile, and displaced among vaccinated Gaps exist in immunization coverage across many and districts, pockets of populations are under- The biosecurity situation is essentially unknown; there is no inventory of dangerous pathogens. capacitiesLaboratory widely differ in terms of technical and biosafety. capacity No formal multisectoral coordination mechanisms currently exist. publicon health concerns. The current workforce development strategy should strengthened be to include sufficient focus used as practice abest model for other diseases. programmeThe TB tiered with its approach to laboratory testing, surveillance and control canbe diseases. zoonotic relevant on focuses Programme Management Vector Integrated The The veterinary workforce is capable and sufficient. Incentives (hardship allowances) exist to retain the health active workforce. FELTP-trained are vets now focusing on zoonotic diseases. A human resources strategy and aseparate public health management cadre are in place. 81 of IHR Core Capacities of the Islamic Republic of Pakistan OTHER 82 OTHER

Joint External Evaluation ing samplestoNIH. little ornopoint-of-caretesting. There isnoEQASorcontingencyfortestingpriority diseasesexceptsend- laboratories testforafewselectedpathogens. There isa lackofaneffectivesampletransport systemand AMR testingcapacityisavailable androutinelyperformedinanimalhealthlaboratories; humanhealth for samplesreceivedfromthemoreperipheral areas. is noBSL-3laboratory. PPE isgenerally unavailable orstaff untrained touseit. There isno tracking system Some biosafetyandbiosecuritytraining hasbeenconductedrecentlybyNGOswithin the province. There planned forthenearfuture. risk assessment and analysis. In the areas of workforce development, no strategy or policy is present or lio); laboratory, biosafety andbiosecurity; andEPRoperations (EOCcatersonlyforPolio), withnohazard/ to publichealththreatsatitsmajorinternationalairportinQuetta; riskcommunication(again, onlyforpo- linkages betweenanimalandhumanhealthsurveillanceforzoonoses; detectionandresponsecapacities systems inthefollowingareas: diseasesurveillance(essentiallyonlyforpolioand TB plus Avian Influenza); This low/poorshowingontheimmunizationindicatorismirroredbysimilarlylowgrading ofcapacitiesand poor transportation access, immunizationcoverage isextremelylow(estimatedin2012tobeonly16%). Being sparselypopulatedwithachallengingterrain, coupledwithwidelyprevalent underdevelopmentand try’s totalpopulation. The populationofBalochistanwas estimatedtobearound13millionin2012, approximately 7%ofcoun- Balochistan’s population density is very low due to the mountainous terrain and scarcity of water sources. entire country. Gawadar seaportalsoplaysasignificantroleintheeconomicdevelopmentofprovince. provincial economyisdominatedbynatural resources, especiallyitsnatural gasfields, whichsupplythe It sharesborderswith Afghanistan tothenorthandIran tothewest. Although largelyunderdeveloped, the Balochistan islocatedinthesouth-westernregionofcountry; itscapitalandthelargestcityisQuetta. Technical areasassessed: zoonosis, immunization, surveillance, preparedness, EOC, IHRcoordination, PoE Balochistan trengths/best practices trengths/best S – – – – – – – – – – – – – – – – – – health facilities. The Public–Private Health Initiative provides public health care at approximately of 40% peripheral laws, safety Food and field for assets monitoring and laboratory testing are available but limited. Basic laboratory is available capacity care at hospitals tertiary in the public and private sectors. Veterinary human resources are available at district level; FELTP also has veterinarians. Some data sharing occurs with FAO. Currently infrastructure is in place to test for foot and mouth disease. successfully. implemented is surveillance Avian influenza diseasesPriority in the animal are sector well understood but no notifiable disease list is available. Health (Provincial Disease Surveillance and Response Unit), and with contact livestock as required. A CCHF Task Force is notified,with a pointfocal of the Office Director in theGeneral of Public Recommendations for priority actions Recommendations forpriorityactions strengthening/challenges need that reas A – – – – – – – – – – – – – – – – – – – – – – relevant especially sectors, the animal health sector. amultisectorNotify IHR Task Force at provincial level as acoordination mechanism across all Stop wild poliovirus transmission in 2016. a risk communication strategy especially to improve acceptance of immunization. Improve immunization coverage through strong outreach to cover the geographical periphery, and terrain. mountainous in populations scattered to coverage and Develop multi-hazard EPR plans based on hazard analysis, and field test these to ensure access and include these in the developmental plans of Gawadar seaport. internationalQuetta and airport the health at post the border crossing with Afghanistan and Iran, At the federal level, establish minimal levels of public health and assets capacities under IHR at testing. Augment implementation existing of laws and regulations monitoring including and safety food transportation. Establish and enhance for public capacity health laboratory diagnostics and sample shipment and approach. diseases within health, human and between and animal health for zoonoses under the One Health formal multisectoral coordination mechanisms for surveillance, and response for priority reporting, Establish disease active surveillance with peripheral coverage by establishing or strengthening Develop the workforce at strategic and levels policy in this significantly underdeveloped province. present significant challenges strengtheningto public health. The underdevelopment of the province, extensive its terrain, and the dispersed population all strengthened. Balochistan’s overall capacities and capabilities are weak; the very entire structure must be 83 of IHR Core Capacities of the Islamic Republic of Pakistan OTHER 84 OTHER

Joint External Evaluation infrastructure. However, theydodetectprioritydiseasessuchascholera, anthrax, diphtheriaandtyphus. both medicalandveterinarydisciplines, whichdonotattract externalfunding, have limitedresourcesand the NRLPDandreferencelaboratory forfootandmouthdisease. General bacteriologylaboratories in specific individuals. Few laboratories areaccreditedtoanISOstandard, although notableexceptionsare of humanresourcecapacityisrequired, especiallywithinthereferencelaboratories, whicharerelianton complex technologysuchasgenesequencing. Stafftraining isgenerally highalthoughcontinuedbuilding in thistransport. Somelaboratories havegoodinfrastructure andafewevenBSL-3facilitiesaccessto lished process for the transport of samples from remote regions to Islamabad, with staff recently trained and thereferencelaboratories receivesamplesfortestingfromallotherprovinces. There isawellestab- Islamabad. This placesIslamabadinapositionofleadershipnationally. All prioritydiseasescanbetested The NIH, NRLPD, national TB referencelaboratory and otherlaboratories withgoodcapacityallresidein incinerators, withwaste heldinrelativelysecureareasduring disposal. biosecurity. Generally there isadequatebiohazardwaste disposalwithreadyaccesstoautoclavesand at the NIH and the national veterinary laboratories showed little evidence of a systematic approach to for Foot andMouthDisease–arebothISOaccreditedmanipulatehigh-riskpathogens. Laboratories ties visited–theNationalReferenceLaboratory forPoultry DiseasesandtheNational Reference Laboratory Islamabad); thelaboratory atthePoly Clinicprovidesdiagnosticcover. The animalhealth diagnosticfacili- laboratory forthePakistan InstituteofMedicalSciences(theleadingtertiarycareandteachinghospitalin tity. The territoryhoststhenationalreferencelaboratory atNIH(which, however, isafederal institution), the EPR operations arecateredforbytheNDMA, whichisawell-established, staffedandfundednationalen- but is lower in rural areas underscoring poor health service availability, access and utilization in these areas. safety andmonitoringprogramme inthecity. Immunizationcoverage exceeds90%inurbanpartsofICT, rural Islamabad. The CDA’s healthsectionrunsdispensariesforurbanpopulationsofIslamabadandafood Islamabad manages the dispensaries, basic and rural health centres and the community health workers in of InteriorandtheCapital Administration andDevelopmentDivision(CADD). The districthealthofficer ICT hasafragmented healthservicesinfrastructure dividedbetweenICTadministration undertheMinistry ministration ofthecity. Capital Development Authority (CDA)), which oversees the planning, development, construction, and ad- and rural areas. The mainadministrative authorityofthecityis the ICT Administration (assistedbythe Islamabad Capitol Territory (ICT)representsIslamabad, thecapitalcityofPakistan, dividedintoitsurban Islamabad Capitol Territory trengths/best practices trengths/best S – – – – – – – – – – – – Capacity for disaster/crisis for isexcellent. management Capacity Personnel are well trained in both human and animal sectors. National reference laboratory capacities are functional in human and animal health sectors. There is overall good participation in for ad hoc projects CCHF and brucellosis. A multisectoral health forum has been established. surveillance. avian influenza for exists capacity Excellent Recommendations for priority actions Recommendations forpriorityactions strengthening/challenges need that reas A – – – – – – – – – – – – – – – – Conduct regular simulations and drills to practise emergency response and crisis management. and response emergency regularsimulations drills practise and to Conduct strategies. Improve immunization access, availability and acceptance in rural areas using risk communication umbrella. Health One the under laboratories reference health public provincial support Designate NIH and animal heath reference laboratories as lead to serve technical resources to in all major laboratories coordinated under the One Health umbrella at level. ICT Develop and implement a national biosecurity programme, with biosafety regulations and officers sharing andzoonoses reporting/data animal with health and wildlife. Establish formal coordination mechanisms for disease surveillance diseases, including for priority Combine the fragmented health delivery service structures under and ICT CDA into asingle service. diseases. priority external funding, have limited resources and infrastructure despite that the fact they address General bacteriology laboratories in both medical and veterinary disciplines, which do not attract A workforce strategy needs to developed be for ICT. 85 of IHR Core Capacities of the Islamic Republic of Pakistan OTHER 86 OTHER

Joint External Evaluation Initiative, whilecommunity-basedworkers areunderthedepartmentofhealth. this fromthefederal government. PrimaryhealthcarefacilitiesaremanagedbythePublic–Private Health officer ofeachthe10districtswhoworkunderdepartmenthealthhastorelyonassistancefor line publichealthprofessionalsareneeded. GBhasnocapacitytodealwithoutbreaks: thedistricthealth There areseriousworkforcedeficienciesinGB. MoreengagementfromFELTP aswelltraining offront- where healthindicatorsarefarbetter. health-care system does provide health-care coverage under Agha Khan health services in few GB districts, EPR, orriskcommunication(exceptpolio). Immunizationcoverage (exceptforpolio)isalsolow. A private whole. Nocapacity/systemsexistfordiseasesurveillance, reporting, laboratory, medical/nursingeducation, With extremeweatherandhighmountainousterrain, GBissparselypopulatedandunderdevelopedasa is themajorsourceofincome, mostlyintrekkingandmountaineering. glaciers outsidethepolarregionsandspreadsoveranareaof28 000 squaremiles(73 000 km2). Tourism Highly mountainous, GBhasapopulationofunder2million. GBishometothreeoftheworld’s longest and thusadefactoprovince-like status. Ithas Afghanistan asaborderinthenorthandChinatoeast. ofPakistanan Orderwas thatgranted signedbythe President self-ruletothepeopleofGilgit-Baltistan, Gilgit-Baltistan (GB) is the northern most part of the country, the capital city of which is Gilgit. In 2009, Gilgit-Baltistan Recommendations forpriorityactions strengthening/challenges need that reas A practices trengths/best S – – – – – – – – – – – – – – – – – – – – – – Establish medical and nursing schools within GB. administrative territory. Prioritize workforce development at strategic and levels policy in this significantly underdeveloped terrain. mountainous in populations scattered for response emergency during coverage and Develop multi-hazard EPR plans based on hazard analysis, and field test these to ensure access Afghanistan. and China with crossing Establish minimal levels of public health and assets capacities under IHR at health at land posts Establish areference laboratory, and sample shipment and transportation capacities. Designate provincial a 24/7 communication FP IHR with capacity. and reporting Health approach. diseases within health, human and between and animal health for zoonoses under the One multisectoral coordination mechanisms for surveillance, and response for priority reporting, Establish disease surveillance with peripheral coverage by strengthening and establishing formal Immunization coverage (except for polio) is low. education, EPR, and risk communication (except polio). medical/nursing laboratory, surveillance, reporting, disease for exist capacity/systems No interventions. security health and development health shoulder Tourism and local mining if efficiently assets, managed, could generate financial resources to especially for maternal and child health. Public health-care sector delivery is augmented by the private to provide sector health care, Recommendations for priority actions Recommendations forpriorityactions strengthening/challenges need that reas A practices trengths/best S and coverage. overarching workforcestrategy. Food safetyregulationsexistbutrequiresupportforeffectiveenforcement ment isapriorityareafortheGovernment, andacademicinstitutionsin AJK areexpanding, thereisno systems havebeengivendueattention, managedbythe AJK armoftheNDMA. While workforcedevelop- between humanandanimalhealthauthorities. Learningfromthedevastating earthquake in2005, EPR tion coverage, afunctioningsurveillanceandreportingsystem, andapandemic-ledcollaboration system provincial rolesandresponsibilities. These includeimmunisationanprogramme reachinghighimmuniza- AJK hasfairlywelldevelopedcapacitiesinthoseIHR/GHSA-relatedtechnicalareaswhicharepartofthe lack ofcareerdevelopment, jobopeningsortraining forlaboratory professionals. Kashmir, despiteitsthreemedicalcollegesinthepublicsectorandoneprivate sector, thereisstilla Government. Ithasaliteracy rate ofover60%, quitehighcomparedtootherprovinces/territories. In Azad ism, and foreign remittances. While similar to GB, AJK largely depends on fundingreceivedfromthe federal reconstruction ofinfrastructure isunderway. AJK’s economy largelydependsonagriculture, services, tour with widespreaddevastation. Sincethen, withhelpfromtheGovernmentofPakistan andforeigndonors, city. peopleandleftanotherthreemilliondisplaced,A majorearthquake in2005killed100 000 Kashmir bythedefactoborderbetweenIndiaandPakistan. The capitalisMuzaffarabad, thearea’s major mated populationof5million. Intheeast, itisseparated fromtheIndian-administeredstateofJammu and The stateof Azad Jammu andKashmirisaself-governingadministrative territoryofPakistan withanesti- Kashmir and Jammu Azad – – – – – – – – – – – – – – – – – – – – – – Conduct regular simulations with scenarios based on hazard analysis. Designate provincial a 24/7 communication FP IHR with capacity. and reporting zoonoses, disease outbreaks, and emergency response under aOne Health approach. Establish formal intersectoral coordination mechanisms for disease surveillance and reporting for regulations safety Food exist but require enforcement for support effective and coverage. No overarching workforce strategy exists. A laboratory is housed within the provincial university. capacities. There is acute awareness of the need for and significance and efficient of effective EPR plans and high. also is coverage Immunization functioning. ispartially system surveillance indicator-based An Medical schools exist and the education scene is expanding. high. are rates literacy Population - 87 of IHR Core Capacities of the Islamic Republic of Pakistan OTHER 88 OTHER

Joint External Evaluation from theFATA administration tomeetanddiscussIHR/GHSA-relatedissues. Unfortunately ongoingactiveconflictandsecurityconcernsprecludedavisitbytheJEEteamand/orstaff only 3.1%resideinestablishedtownshipsandthusFATA isthemostrural administrative unitinPakistan. ment. According to2011estimates, thistribalpopulationwas estimatedtobeabout3.3million, although stan, bordering Afghanistan tothewestandnorth. FATA aredirectlygovernedbyPakistan’s federal Govern- The federally administeredtribalareas(FATA) aresemi-autonomoustribalregionsinnorth-westernPaki- Federally administered areas tribal Mission teammembers • • • • Limitations andassumptions • • • • Objective Punjab, andSindhprovinces. Gilgit-Baltistan, and the Federally Administered Tribal Areas) and also in Balochistan, Khyber Pakhtunkhwa, in thecapitalcityofIslamabad(nationalauthorities, IslamabadCapitol Territory, Azad, Jammu andKashmir, This missiontookplacefrom27 April to6May2016. The teamheldmultisectoral discussionsandsitevisits Mission placeanddates Annex: evaluation Joint background external agreed between theagreed host and country between assessment team. This is apeer-to-peer review. verified. Information provided by Pakistan was discussed and an assessment rating was mutually The assessment is not an audit, and information provided by Pakistan will not independently be It is assumed that the results of this assessment will made be publicly available. site. anygiven at available expertise For the assessment of provincial capabilities, the Team was divided into five groups,which limited the managed.could be The assessment weeks’ was ofduration, two which limited the amount and depth of information that for globalcapacities health security. Recommend actions priority to update and finalize the national plan to achieve and maintain IHR Develop describing areport the progress and gaps in implementing the IHR capacities; and documents; related all Review entry; of points at including events health the implementationAssess of the IHR public health capacities for surveillance and response to public – – – – – – – – – – – – – – – – – – – – Ghazi Lebanon Kayali, Human Link, Hamid Jafari, Centers for Disease Control and Prevention, United States of America Kashef Ijaz, Centers for Disease Control and Prevention, United States of America Khalid Hamaid, Abu Ministry of Health, Kingdom of Saudi Arabia Michele Forzley, Public Health Legal Advisor, Forzley &Associates, United States of America Australia Laboratory, Reference National Dimech, Wayne Abdullah Assiri, Ministry of Health, Kingdom of Saudi Arabia Karen Sliter, Department of Agriculture, United States of America (Team Co-Lead) Mika Salminen, National Institute for Health and Welfare (THL), Finland (Team Co-Lead) Brian McCloskey, Public Health England, United Kingdom (Team Co-Lead) 89 of IHR Core Capacities of the Islamic Republic of Pakistan 90

Joint External Evaluation Strategic PlanningDepartment, General Headquarters, Rawalpindi Social SecurityHospital, Rawalpindi Pakistan NuclearRegulatory Authority Pakistan Atomic EnergyCommission National Tuberculosis Control Programme National InstituteofHealth National HealthEmergencyPreparednessResponseNetwork National EmergencyOperations Cell National DisasterManagement Authority National Agricultural ResearchCouncil Ministry ofNationalHealthServicesRegulationsandCoordination Ministry ofLawandJustice Ministry ofFood SecurityandResearch Ministry ofClimateChange Expanded Programme onImmunization District HealthOffice, IslamabadCapital Territory Directorate HealthServices, CapitalDevelopment Authority Central HealthEstablishments F P Health Services, RegulationsandCoordination, Pakistan Dr MalikMuhammadSafi, DirectorofPrograms and Focal Point oftheJEEMission, MinistryofNational P K ederal level articipating institutions institutions articipating representative lead akistan ey hostcountryparticipantsandinstitutions – – – – – – – – – – – – – – – – – – Irshad Shaikh, World Health Organization, Regional for the Eastern Office Mediterranean headquarters Organization Health World Kandel, Nirmal Thomas Hofmann, World Health Organization, Regional for Europe Office Christina Banluta, World Health Organization, Regional for the Eastern Office Mediterranean Sareen Shashi, and Food Agriculture Organization, RegionalAsia for and the Office Pacific Kleio Stoidou, Independent Public Health Legal Advisor, Greece Saikat,Sohel Public Health England, United Kingdom Mohammed Moussif, Public Health Morocco Department, Egypt Authority, Regulatory Radiological Wael and Khouly,Nuclear Government ofSindh, Department of Agriculture, Supplies andPrices Provincial IHRFocal Point Government ofSindh, Department ofHealth, ProvincialEPIProgramme Government ofSindh, DepartmentofHealth Emergency Operations Cell Directorate ofCentral HealthEstablishments 2. Sindh jhota Expressrailway serviceoperating betweenPakistan andIndia) Wagah Border, Lahore(landcrossingbetweenPakistan andIndia)including Wagah Railway Station(Sam- University of Veterinary and Animal Sciences, Department ofLivestock, Lahore Shaikh ZayedHospital, Lahore Shaukat KhanamMemorialHospital, Pathology Unit, Lahore(private sectorlaboratory) Provincial IHRFocal Point Provincial Focal Point forRiskCommunication Provincial EmergencyOperations Cell Provincial DiseaseSurveillanceandResponseUnit Mayo Hospital, Lahore Institute ofPublicHealth, Lahore Government ofPunjab, MinistryofLivestockandDairyDevelopment Government ofPunjab, ProvincialEPIProgramme Government ofPunjab, DepartmentofHealth Government ofPunjab, DepartmentofEnvironmentProtection Government ofPunjab, Departmentof Agriculture Allama IqbalInternational Airport, Lahore, 1. Punjab levels regional and rovincial P World HealthOrganization United States Agency forInternationalDevelopment United NationsProgramme forHIV/AIDS United NationsPopulation Fund United NationsChildren’s Fund Food and Agriculture OrganizationoftheUnitedNations Health developmentpartners 91 of IHR Core Capacities of the Islamic Republic of Pakistan 92

Joint External Evaluation Government of Balochistan, Department ofPlanningandDevelopment Government ofBalochistan, DepartmentofIndustriesandCommerce Government ofBalochistan, DepartmentofHealth, ProvincialEPIProgramme Government ofBalochistan, DepartmentofHealth, EmergencyOperations Cell Government ofBalochistan, DepartmentofForests and Wild Life Government ofBalochistan, DepartmentofFood Government ofBalochistan, DepartmentofEnvironment Supportsand Youth Affairs Government ofBalochistan, Departmentof Agriculture andCooperatives Bolan MedicalComplexHospital, Quetta 4. Balochistan Provincial TB ControlProgramme, Laboratory Section(BSL-3laboratory) Provincial IHRFocal Point Khyber MedicalUniversity, Peshawar Integrated DiseaseSurveillanceandResponseUnit/Provincial ResponseUnit Hayatabad MedicalComplex, Peshawar Government ofKhyberPakhtunkhwa, ProvincialDisasterManagement Authority Government ofKhyberPakhtunkhwa, DepartmentofPlanningandDevelopment Government ofKhyberPakhtunkhwa, DepartmentofHealth Government ofKhyberPakhtunkhwa, DepartmentofFood Government ofKhyberPakhtunkhwa, DepartmentoftheEnvironment Government ofKhyberPakhtunkhwa, Departmentof Agriculture andLivestock Emergency Operations Centre, Peshawar Director General ofHealthServices, ProvincialEPIProgramme Director General ofHealthServices, HealthEmergencyPreparednessandResponseUnit 3. KhyberP Seaport, Karachi Quaid e Azam International Airport, Karachi Government ofSindh, MinistryofLivestockandFisheries, Tando Jam Agriculture University Government ofSindh, MinistryofLivestockandFisheries, SindhPoultry Vaccine Centre, Karachi Government ofSindh, JinnahPost Graduate MedicalCentre, Karachi Government ofSindh, DepartmentofPlanningandDevelopment Government ofSindh, DepartmentofIndustriesandCommerce Government ofSindh, DepartmentofForest, Environment& Wildlife Government ofSindh, DepartmentofFood akhtunkhwa • • • • • • • Supporting documentationprovided byhost country Directorate HealthServices, Peshawar 7. Government of Azad Jammu andKashmir, Department ofSports, Youth andCulture Government of Azad Jammu andKashmir, Department ofFinancePlanningandDevelopment Government of Azad Jammu andKashmir, Department oftheEnvironment Government of Azad Jammu andKashmirDepartmentofIndustries Government of Azad Jammu andKashmir, Department ofForests Government of Azad Jammu andKashmir, Department ofFood Government of Azad Jammu andKashmir, Ministry ofInformation, Agriculture andLivestock Government of Azad Jammu andKashmir, Department ofHealth 6. Government ofGilgit-Baltistan, MinistryofLivestockandDairyDevelopment Government ofGilgit-Baltistan, DepartmentofHealth Government ofGilgit-Baltistan, DepartmentofForest, Wildlife, EnvironmentandCommerce Government ofGilgit-Baltistan, DepartmentofFood and Agriculture, LivestockandFisheries 5. Gilgit-Baltistan Quetta Airport Provincial IHRFocal Point Provincial DiseaseSurveillanceandResponseUnit Provincial DisasterManagement Authority Government ofBalochistan, MinistryofLivestockandDairyDevelopment Azad Jammu &Kashmir(AJ) F ederally Administered T links for the 19 technical areas of the JEE tool Online repository of supporting documents, notifications, datasources, previous assessments and web JEE experts). Agendas for technical meetings and federal and provincial site visits (including individual agendas for Technical area presentations on each of the 19 technical areas of the JEE tool (27–29 April 2016). Presentation on overview of the health system in Pakistan (JEE assessment mission, 27 April 2016). 2016). April 4–8 workshops orientation (preparatory Pakistan in implementation IHR of status current the on Presentation 2016). April 4–8 orientation workshops, (preparatory GHSA and JEE IHR, on assessment Presentation orientation on health of sectors and non-health Self-reporting on JEE assessment tool, Pakistan. ribal T erritory 93 of IHR Core Capacities of the Islamic Republic of Pakistan Joint External Evaluation of IHR Core Capacities of the Islamic Republic of Pakistan

Mission report: 27 April – 6 May 2016

WHO/WHE/CPI/2017.9