Stewarding COVID-19 health systems response in Pakistan: what more can be done for a primary health care approach to future pandemics?

Abstract

We apply a primary healthcare (PHC) perspective to gauge Pakistan’s health systems response to COVID-19, to identify stewardship lessons for integrating the PHC pandemic response. Analysis of Pakistan’s response against the Astana PHC framework shows that the imperative for national survival helped mobilise an agile response across a fragmented health security context. The findings show effective multisector governance in responding to the health and social aspects of the pandemic, as well as the rapid roll-out of several public health functions and emergency care. However, we found weak maintenance of essential health services and ad hoc, short-lived efforts for community engagement.

Critical enablers that helped steward the response across complex power-sharing arrangements included solidarity across society, collaborative data-driven decision-making, leveraging of siloed domestic resources and private sector coordination. At the same time, a more PHC-centric response was constrained by weak political prioritisation of essential health services, uneven services, weak direction to civil society volunteerism for community engagement and weak regulation of private sector contribution.

We conclude that a mindset shift is required from short-term tactical measures to long-term investment in PHC-oriented transformative stewardship. Future preparedness must build attention to essential service package for emergencies, mobilisation of both private and public primary care providers, effective community engagement vision across societal actors and market regulation, within a collaborative governance framework.

SUMMARY BOX.

• Globally, much is known about how countries responded to the pandemic crisis, but less is known on critical enablers and barriers to steward a more primary healthcare (PHC)-centric response.

• Collaborative governance backed with digital data, societal solidarity, private sector coordination and pre-existing humanitarian assistance networks served as key enablers in Pakistan successfully stewarding a health systems response across a heavily decentralised and fragmented health security context.

• An over-riding focus on clinical surge capacity overlooking maintenance of essential health services, highly uneven essential services and inability to translate volunteerism into longer-term community support, constrained stewardship from being more PHC-centric.

• Future efforts must be directed to support long-term PHC-oriented measures comprising of inclusion of primary care providers within pandemic planning, standardised essential services for emergency situations, a community engagement strategy that extends beyond the acute phase and market regulation capacity.

Introduction

The COVID-19 pandemic stressed country health systems in responding to the unexpected surge of cases while attempting to maintain continued access to essential health services.¹ Pakistan performed better than many other low-middle-income countries in terms of COVID-19 health and social-economic impact. Multi-country analysis of COVID-19 case load and mortality ranks Pakistan at eighth out of 35 countries.² Despite experiencing three waves of COVID-19 from 2020 to July 2021, Pakistan’s case fatality rate remained relatively low between 2.13 and 2.7 per 1000 population³ translating into 134 reported deaths per 1 million population, substantially lower than neighbouring countries of Iran and India with respective figures of 1707 and 379 deaths per million population.⁴ The country emerged from lockdowns early during the first wave opting to incrementally resume operations across all sectors and adapt operational working in line with the pandemic’s evolution.⁵

The WHO emphasises building on COVID-19 response efforts of countries to simultaneously strengthen national pandemic preparedness as well as integrate disease security within universal health coverage.⁶ Primary healthcare (PHC) is underscored as the centre piece of larger efforts for essential public health functions, emergency preparedness and International Health Regulations (IHR) for building pandemic resilience.⁶ Pakistan’s relative success in response to COVID-19 was characterised by a decisive and wide range of measures adopted across a heavily decentralised country context;⁷ at the same time, not all public health functions were evenly addressed in the country’s response.⁸

This analysis aims to provide an understanding of Pakistan’s navigation of the early health systems response to the pandemic from March 2020 to June 2021 and identify what more must be done for integrating a PHC approach to counter future pandemics. Experiential insights are drawn on with key aims of (1) assessing the extent to which a PHC-centric approach was integrated within the national COVID-19 pandemic response and distil unmet needs; (2) identifying barriers and enablers for effective stewardship of a PHC-centric response to future pandemics. We draw on thematic descriptive analysis of policy documents, official notifications, observational data from electronic registries, district health information systems, published papers as well as informed interaction with country stakeholders inclusive of government officials, private health sector, civil society organisations (CSOs), development partners and experts, building further on a qualitative country case study examining PHC in the context of the COVID-19 pandemic in Pakistan.⁹ The WHO’s Astana PHC framework¹⁰ is applied to unpack and understand the health systems response against the three thematic areas of how primary care and essential public health functions responded to COVID-19; community engagement- communication and preparedness and multisectoral engagement to counter health-social consequences.

How primary care and essential public health functions responded to COVID-19

Preparedness context for disease emergency response: systems, governance and policy commitment

Pakistan has a mixed health system comprising of tax-funded free government health services and a robust private sector that includes both for-profit and philanthropic organisations operating on a fee-for-service basis.¹¹ Healthcare utilisation is segmented across the public and private markets with the formal private facilities responsible for 70% of outpatient PHC visits; private laboratories are the main source of diagnostics, whereas the public sector is the major provider of vaccination-preventive care delivered through a large community-based health workforce.^{12 13} Cross-referrals between the public and private providers were not coordinated prior to the pandemic. Disease surveillance sentinel sites were established by the National Institute of Health supported by a Public Health Act but remained confined to a few public and private hospitals.

Pakistan’s health security landscape has been constrained by fragmented resourcing, low ownership and coordination challenges across a decentralised health system. Although Pakistan is the eighth largest aid recipient for health security,¹⁴ funding has been narrowly concentrated on Polio eradication. Extensive PHC-based Polio surveillance and communication mobilisation network has historically been in place but not leveraged to other diseases. Moreover, public health functions in decentralised Pakistan are distributed across federal-provincial governments (table 1) requiring joint resourcing for PHC-centric disease control responses; however, federal-provincial government coordination has been challenging in the prepandemic years. Policy support for health security and emergency preparedness programming across all levels of government has been weak. A National Action Plan for Health Security¹⁵ supported by an IHR Taskforce was approved in 2019 informed by a WHO Joint External Evaluation mission,¹⁶ but did not get programmed due to inadequate funding support. On a parallel footing, an essential services package has been developed for Universal Health Coverage but yet to be integrated into pandemic planning.^{17 18} The COVID-19 crisis catalysed different parts of the health system and intersectoral stakeholders to work together for a public health response.

Table 1. Roles and authority for disease response across a decentralised context.

Federal	Provincial
Resourcing: 16% of total government spend*Direct allocation from federal budget	Resourcing: 84% of total government spend*Direct allocation from provincial budgets
Stakeholders: Ministry of National Health Service Regulation and Coordination (MoNHSRC), National Institute of Health, Drug Regulatory Authority	Stakeholders: Department of Health in each of the provinces
Functions: International Health Regulations (IHR), drugs/vaccines/technology (licensing, registration, pricing, imports/exports), disease surveillance, disease reporting, standard setting, risk communication guidelines	Functions: service delivery reforms and planning, service delivery models, supply chain management, workforce management, operations monitoring, market regulation, purchasing healthcare services
Human resource: policy, public health disease surveillance staff	Human resource: policy, public health, disease surveillance staff; healthcare delivery workforce

^*National Health Accounts Pakistan 2019–2020; Federal Legislative List I and II.

Scaling up and managing services related to COVID-19

The COVID-19 pandemic started in Pakistan in March 2020, escalating to a full-blown wave by July 2020 and was followed by two consecutive waves until July 2021. Statistics over this time show 21 655 cumulative deaths and a recovery rate of 94%–96% (table 2). Public sector hospitals bore the brunt of admissions whereas private hospitals were reluctant to admit COVID-19 patients for fear of infection spread and disruption of routine inpatient procedures.¹⁹ Pakistan effectively built surge capacity through close coordination with private hospitals but remained less successful in providing affordable access to testing and treatment. Successful negotiations by provincial governments resulted in private hospitals opening critical care facilities and inpatient admissions to COVID-19 patients, hence allowing public sector hospitals to function to threshold capacity^{20 21} (see box 1). In some provinces, having high private hospital concentration, up to 40% of bed capacity was drawn from private hospitals.²¹ Cross-referrals between private and public hospitals were coordinated through newly established government telecall centres and WhatsApp groups to divert admissions to hospitals with bed capacity. Ambulance services were linked with the telecall centres to coordinate patient pick-up and transfer across hospitals. Several Standard Operating Procedures and training were made available for health staff, to the extent that duplicative guidelines emerged from multiple public sector and civil society entities. Attention to building surge capacity was largely focused on major cities; however, secondary cities faced continuing challenges of less-equipped infrastructure, fewer skilled staff and insufficient ambulances to transport patients to referral hospitals.⁸

Table 2. COVID-19 pandemic in Pakistan (1 Jan 2020–3 June 2021).

COVID-19 data	Pakistan	Capital city: Islamabad	Punjab	Sindh	Khyber Pakhtunkhwa	Baluchistan	Federally administered areas
Confirmed cases	947 976	81 540	341 390	321 425	133 746	25 476	25 011
% Distribution of confirmed cases		8.78%	36.76%	34.61%	14.40%	2.74%	3%
Deaths	21 655	763	10 184	5089	4125	287	657
Case fatality rate	2.30	0.93	2.98	1.58	3.08	1.12	2.6
Recovered	874 027	77 062	314 334	292 001	125 058	24 129	23 421
Recovery rate (%)	92%	94.40%	92.07%	90.84%	93.50%	94.71%	94%

Adapted from Zaidi S, Hussain SS 2022. Pakistan: a primary healthcare case study in the context of the COVID-19 pandemic. Geneva: World Health Organization; 2022. License: CC BY-NC-SA 3.0 IGO.

Box 1. Building surge capacity by harnessing private providers.

• Market expansion for testing and treatment

Government-designated COVID-19 testing sites across public and private providers.

Negotiation with private providers for COVID-19 admissions.

Cross-referrals across public and private hospitals supported by telecall centres, WhatsApp group, ambulance pool.

Facilitation of supplies and reagents to private laboratories and hospitals.

Interest-free loan support to private hospitals for maintaining business.

• 2Attempts for affordable access to COVID-19 services

Affordable COVID testing (Khyber Pakhtunkhwa): prequalifications of private laboratories on minimum quality standards carried out for the purchase of COVID testing services through government financing, not carried to completion and instead market facilitation adopted, as elsewhere in the country for privately provided testing at full fee rates.

Affordable hospital admissions (Punjab): legislations related to the Pakistan Medical and Dental Council Act for private medical colleges to provide affordable access were enforced with two large private teaching hospitals to provide 50% COVID beds to non-affording patients. Medicine and supply costs provided by the Punjab Health Department whereas bed costs and consulting costs borne by private hospitals.

Affordable hospital admissions (Sindh): formal agreements with major private hospitals for government purchase of critical care beds for non-affording patients at existing private hospitals tariffs, but not operationalised due to private hospitals obtaining sufficient volumes from private fee-paying COVID patients.

Affordable hospital admissions (Khyber Pakhtunkhwa): management contracts for COVID-19 services at two secondary government hospitals through outsourcing to non-government organisations with World Bank financing support.²³

• 3Health workforce training across private and public providers

Internationally accredited private hospitals provided infection control training to government hospitals through partnership agreements (Sindh).

Government teaching hospitals provided training to public and private hospitals (Punjab).

Healthcare commissions provided training to general practitioners, laboratory technicians (Sindh, Khyber Pakhtunkhwa, Punjab).

Access to COVID-19 testing was significantly boosted by efforts to integrate all clinical and scientific laboratories, with PCR testing capability, into the national response. A total of 199 laboratory networks—comprising 58 public sector laboratories, 124 private, 7 public–private and 10 from the army medical corps—were identified, designated as officially designated testing sites and supported to secure testing kits and reagents.²² More than 50% of the case load was provided by private laboratories due to superior batch capacity, better-equipped facilities, speedy e-reporting systems and collection units across the country. Despite the availability of well-developed laboratory networks in Pakistan, testing volumes remained lower than required due to public hesitancy for testing,²³ with up to three times higher cases indicated by modelling results.²⁴ This is reflected in national statistics of 42 564 tests conducted per 1 million population in Pakistan as compared with neighbouring Iran’s 139 018 per 1 million and India’s 1 632 000 per million population.⁸ Low rates of testing hampered pandemic monitoring and must be addressed for future responses.

Governmental strategy remained focused on market facilitation rather than market regulation. Price regulation of private testing and admissions was deliberated but not undertaken for fear of disincentivising private healthcare provision, which was considered critical to the surge response. Although minimum quality standards for COVID-19 were quickly developed by provincial healthcare commissions, these were applied to designate laboratories as official testing sites in only one of four provinces. Government subsidies for private laboratory testing were deliberated by policymakers but considered unaffordable, given the magnitude of the pandemic. Although Pakistan has a national health insurance scheme, there was little attempt to regulate insurance to introduce COVID-19 inpatient admissions within the beneficiary package. Other attempts at securing financial access to inpatient beds for the poor was attempted but met with varying success. For example, in one province (Sindh), tariffs with private hospitals were negotiated for non-affording patients but could not be implemented (Sindh). Another province (Punjab) developed regulations for affordable access to beds for poor patients in private hospitals. In yet another province (Khyber Pakhtunkhwa), efforts were made to procure private management expertise using management contracts to maximise the capacity of government hospitals for free admissions (see box 1).

Maintaining essential health services

Utilisation of essential health services dipped sharply in the first COVID-19 wave with disruptions seen across outpatient services, reproductive-maternal-child care services (RMNCH) as well as preventive services²² (figure 1). With political emphasis mainly on building surge capacity, the primary care health providers lacked effective direction and resourcing in the early days of the pandemic. Deaths of doctors and paramedics from COVID in the initial weeks of the pandemic created alarm with both public and private health providers suspending outpatient services.²⁵ Assignment of health staff from essential healthcare duties to COVID management in larger hospitals further disrupted essential services.²⁶ Community hesitations to visit health facilities due to fear of catching COVID infection or being forcibly quarantined also contributed to disrupting essential services.²³ PHC facilities faced chronic shortages of personal protective equipment (PPE) as available stocks had to be pivoted to tertiary hospitals.^{27 28}

Figure 1. Essential Health Service Delivery between Jan 2020 and June 2021 in Pakistan.

Essential health services resumed over time through a combination of digital online support as well as livelihood pressures faced by healthcare providers to return to work. The introduction of televideo consultation for outpatient clinics helped resume essential health services in better-equipped health facilities, whereas lesser-equipped health outfits began operating short-duration OPD clinics.29,31 Government community outreach programmes for routine immunisation resumed, supported by virtual training of workers on managing COVID-19 risks, provision of some PPE support and customised community messages.⁷ Initial lessons from the first wave helped in creating a separate pool of COVID-19 response staff for subsequent waves to minimise disruption to essential services within the public sector. However, insufficient PPE and health worker hesitations of infecting family or incurring catastrophic hospital expense if contracted with COVID continued to undermine essential health services.^{25 29} In contrast to extensive high-level efforts to harness large private hospitals, there was noticeably little attempt to integrate private general practitioners (GPs) for uninterrupted safe essential services, COVID-19 triage and risk communication.^{32 33} Disparities were seen in the extent of financial support provided by the state for healthcare providers. Public sector staff was compensated with increased pay for COVID-19; large private hospitals were provided interest-free loans to maintain operations; however, small-scale private facilities and GPs were heavily impacted by loss of livelihood.

Noticeably, disruption in health services triggered health activism across different segments of the civil society. The Pakistan Medical Association became the platform for voicing collective concerns of primary care providers. A coalition of health practitioners, United Nations (UN) agencies and development partners called ‘Forum for Motherhood’ came together for the protected opening-up of RMNCH services across public and private providers. Similarly, provincial healthcare commissions drew on existing networks with GPs to provide SoPs and offer training from meagre resources. Innovative primary care partnerships were initiated between medical universities and digital start-ups integrating female GPs for the provision of telemedicine services to female clients.^{30 31} Medical students were mobilised to support doctors for COVID-19 passenger screening at airports and support to quarantine hospitals.

Community engagement and empowerment

Pandemic response was confronted with community-based challenges of hesitancy to avail COVID testing and essential health services,³⁴ mental health issues, livelihood issues and increase in domestic violence.³⁵ Community engagement and empowerment were supported by extensive societal volunteerism, availability of existing CSO networks for Polio eradication and humanitarian assistance, as well as strong digital capacity for online communication.

Risk communication, telemedicine, virtual COVID-19 triage services, home quarantine advice and contact tracing applications were rolled out as part of community engagement supported by health departments, national disaster management authority, academic institutions, NGOs and UN agencies.^{7 35} Wide penetration of mobile networks in Pakistan and a fast-growing digital small–medium enterprise sector helped in launching digital community engagement to several million users.²⁹ Better success was seen with telemedicine, virtual triage and home quarantine interventions, response to digital risk communication varied widely by education status of users, whereas contact tracing applications had the least uptake within communities due to fear of societal stigmatisation.³⁶ Absence of a communication plan in the early days of the pandemic allowed disinformation to gain foothold in the media, but a risk communication strategy was quickly implemented to counter COVID-19 misinformation and strengthened through experiential learning during subsequent waves.

Emergence of new community-based influencers was seen during the COVID-19 pandemic, widening the network from community elders and religious leaders as seen in past efforts to include celebrities, youth and media. Sports celebrities, singers, teleindustry personalities and prominent physicians worked closely with government officials to create solidarity and reinforce trust in safety measures on social and electronic media. Additionally, close to 7000 religious leaders were mobilised to deconstruct COVID-19 and emphasise safety measures during the Friday sermons and public dealings.³⁷ Within local communities’ youth groups emerged as community change agents applying their digital skills to support government outreach health workers with COVID-19 risk messaging to communities.

Extensive volunteerism across civil society stakeholders was a hallmark of the early community engagement and empowerment response but later faltered due to a lack of sustained funding and direction. Philanthropic networks, medical associations, social activists and citizen groups provided PPE, supplies for safe drinking water-sanitation-hygiene (WASH), nutrition and essential and mental health services in cities majorly affected by COVID-19. Local CSOs linked to community-based networks for Polio control and humanitarian work were mobilised by the UN emergency cluster for rural disadvantaged areas.³⁷ Although the philanthropic response was quickly galvanised, there was considerable variation in services, approach and community messaging as well as duplicative efforts in certain geographies and lack of effort in other geographies.³⁴ Weak strategic direction constrained the impact of volunteerism. Lack of sustained funding led to tapering out of community relief activities once the acute phase was over and philanthropic resources were exhausted.

Multisectoral stewardship of pandemic control

The immediate economic repercussions from the pandemic triggered a nationwide social, economic and health response led by the political leadership. Whereas the health ministry provided technical advice and data, it was the central planning ministry that steered a multifaceted response across all sectors. Collaborative governance was a key feature bringing together diverse sectors as well as federal-provincial decision makers into a National Command and Control Centre (NCOC) navigating siloed power and resource-sharing arrangements. The NCOC was nested under the prime-ministerial office, led by the Minister for Planning and drew representation from all major entities including the Finance Ministry, Interior Ministry, National Disaster Management Agency, Ministry of Information, Ministry of Food and Agriculture, security agencies, federal health ministry and provincial health departments, Drug Regulatory Authority and local and international medical experts. Similar task forces were established under provincial chief ministers.⁷

A data-driven target operating model was swiftly adopted by NCOC based on daily digital reporting of cases from the COVID-19 registry as well as daily monitoring of hospital bed occupancy, ICU admissions, recoveries and deaths. The digital infrastructure provided by the Global Polio Eradication Initiative (GPEI) was drawn on for digital data reporting and conduction of continuous online hybrid meetings.^{5 20} The NCOC platform was instrumental in deliberating on disease projections and health system capacity needs for national planning and coordinated healthcare and societal decision-making. The presence of trusted societal figures such as senior clinicians, notable philanthropists in the NCOC and provincial COVID-19 task forces helped in positive imaging of government efforts as well as in building solidarity across society.⁹

Several cross-sectoral policy decisions were undertaken ranging from public safety measures, facilitated access and production of medical supplies, ensuring critical surge capacity, SoPs for communal activities and travel, as well as economic measures for local businesses and households’ livelihoods (box 2). Adaptations and relaxations were made on a continuous basis in line with changes in pandemic pattern. The NCOC also introduced compulsory COVID-19 vaccination and oversaw a successful roll-out linked to the national birth and vital registration data, which later became the cornerstone of COVID-19 vaccination delivery. However, links with prior IHR platforms and disease control units were not established during the pandemic response, raising concerns of institutionalising and sustaining the response in the future. The NCOC was later disbanded in 2022 and reconstituted once vaccination levels had reached required thresholds at a smaller scale within the health ministry without the earlier high-level multisector representation. Detailing of some PHC-centric measures such as standardised essential care packages during emergencies and a greater role of community workforce are now being initiated in Pakistan, building on experiential learnings from the COVID-19 response.

Box 2. Pakistan’s National Command and Control Centre for COVID-19: multisector working for COVID-19 response.

• Setting up of supply imports and domestic production lines: regulatory permission by federal health ministry, import process and reduction in levies fast-tracked by ministries of commerce and industries.

• Supplies procurement by National Disaster Management Agency, supplies identified by the federal health ministry and provincial health departments, distribution by provincial disaster management agencies.

• Local supplies production: licensing framework speed fasted by drug regulation control authority, proactive dialogue with industry and scientific institutes for PPE, WASH supplies, remedesvir production and ventilator assembly.

• Risk communication: technical content by federal health ministry, communication by NCOC, digital streaming by digital firms.

• Trace and track measures: digital product development by digital firms, implementation by provincial disaster management agencies, technical guidelines by federal health ministry.

• Economic relief: hardship salary for government health staff, interest-free business loans for private hospitals and small enterprises, policy measures by industry and commerce ministry with State Bank of Pakistan, technical guidance from Ministry of Planning and Economic Affairs.

• Lockdowns, focal lockdowns and regulation of business/routine activities: decision by NCOC and provincial task forces, implemented by interior and home departments, technical advice by federal health ministry and provincial health departments.

• International and domestic travel control—decision by NCOC, technical guidelines by federal health ministry, implementation by Civil Aviation Authority.

• Primary, secondary and higher education delivery: closure of institutions, face-to-face versus online education—decision by NCOC, implementation by Ministry of Education and provincial education departments, technical guidance by Ministry of National Health Service Regulation and Coordination and provincial health departments.

  NCOC, National Command and Control Centre; PPE, personal protective equipment; WASH, water-sanitation-hygiene.

Conclusion

Postpandemic, there has been a global attempt to take stock of national responses to better understand what contributes to a resilient health systems response.³⁸ We analysed experiential insights from Pakistan, applying a PHC perspective to gauge the national response against the Astana framework, with a particular emphasis on stewardship lessons.

Pakistan’s country response assessed against the three domains of the Astana framework demonstrated effective multisector governance in responding to health and social determinants. Our findings show that the imperative for national survival helped mobilise an agile response across a fragmented, inadequately resourced and poorly championed health security context. The findings show effective multisector governance in responding to the health and social aspects of the pandemic and the rapid roll-out of several public health functions including testing, surveillance, surge capacity, cross-referrals, training and risk communication. However, we found weak maintenance of essential health services and ad hoc, short-lived efforts for community engagement.

Globally, how countries responded to the pandemic crisis has been shaped by the international diffusion of practices during a time of crisis, as well as through local assimilation of experiential knowledge from national health systems.^{1 39} Importantly, local response measures have worked in unison with the larger country policy, governance and political context. Effective governance, flexible financing, motivation of health workforce, digital innovations and leveraging health information systems have emerged as important enablers in building effective resilient COVID-19 responses across countries.^{38 40} Private sector coordination was speed fasted by the pandemic in many low-middle-income countries unlocking expertise, services and resources for the response, but governments struggled with regulating the private sector for affordable, quality services.41,43

The Pakistan experience highlights the role of solidarity across society, data-driven collaborative decision-making, leveraging of siloed country resources and private sector coordination as critical enablers that stewarded the response across complex power-sharing arrangements (table 3). At the same time, a more PHC-centric response was constrained by an over-riding prioritisation of acute hospital care over essential health services, weak direction to civil society volunteerism for impactful community engagement and over-reliance on private market facilitation without necessary regulation for quality and affordable access (table 3).

Table 3. Enablers and barriers to health systems response to COVID-19.

Thematic areas	Enablers	Barriers
Preparedness context for disease Emergency Response	Laboratory capacityDisease surveillance mechanism planResources from Polio eradicationUN emergency cluster	Chronic under-resourcing of disease preparednessPoorly functional IHR forumsAbsence of risk management strategy
Building surge capacity to manage critical emergency: Expansion in ICU and hospital bed capacity Cross-referrals Testing sites Surveillance and edata Triage and data Risk communication	Public–private coordinationStrong laboratory capacityDigital capacityMarket facilitationStandard operating procedures	Insufficient market regulation for access to affordable quality services
Maintaining essential health services Introduction of telemedicine services Reopening of outpatient services, maternity, other services Resumption of outreach preventive activities	Large community workforce,Digital infrastructure for telemedicine	Insufficient resourcingLack of integration of private primary care providersUneven menu of services
Community engagement and empowerment Digital risk communication Contact tracing WASH, PPE, nutrition, livelihood support	Multipronged risk communicationStrong digital capacityVolunteerismEstablished humanitarian networks for Polio control and disaster reliefs	Inconsistent, short-lived measuresDifficulty with contact tracingAbsence of longer-term community recovery support
Multisectoral stewardship of pandemic control Health, societal and economic operational decisions, legislations, public guidance Facilitation of supplies production and imports Economic support to health sector Enforcement of public safety measures across sectors Vaccinations	Multisector stewardshipDigital data for decision-makingResource coordination across vertical programme and sectorsSupply chain protection	Weak pre-existing disease control platformsAbsence of continued investment in disease response platformsGuidance from public health experts

PPEpersonal protective equipmentWASHwater-sanitation-hygiene

We conclude that a mindset shift is required from short-term tactical measures to long-term investment in PHC-oriented transformative stewardship. Future preparedness efforts must prioritise an essential service package for emergencies, mobilisation of both private and public primary care providers, a community engagement strategy across societal actors and market regulation. Attention is required to institutionalising the role of multisector governance structures beyond the acute pandemic as these are instrumental in providing consolidated stewardship across fragmented decentralised disease control contexts. Future research is needed on pathways to integrating PHC-centric responses for health emergencies, within a collaborative governance framework.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.