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Ever since the first case reported from Wuhan, China, the exponential rise in new cases of Coronavirus Disease 2019 (COVID-19) across the globe, led to the worst pandemic of 21st century. According to WHO, there were  7,355,981 confirmed cases of COVID-19 and 416,891 deaths till June 12, 2020.1 COVID-19 is not only a major global health crisis with limited knowledge about the dynamics of the disease, but is a serious threat to the global socio-economic status. At present, there is no cure or vaccine available for COVID-19. The strategy of WHO is to guide all countries to slow down the COVID-19 transmission and to protect their health systems.2 WHO has already issued a strategic plan for preparedness and response regarding COVID-19.3 In Pakistan, the first case of COVID-19 was confirmed on February 26, 2020 and currently there are 125,933 confirmed cases of COVID-19 (including 6,397 new cases during last 24 hours) and 2,463 deaths till June 12,2020.4 Although the Government of Pakistan was able to draft a National Action Plan for COVID-19 in March 2020,5 and took initial positive steps as well but the major flaws in implementation strategy, resulted in failures at multiple stages.6 According to WHO report on 9 June 2020, Pakistan has level-2 (≤40%) preparedness capacity for Covid_19.7 No doubt, that the Covid-19 pandemic is an extraordinary situation and even the world’s leading health systems have faced difficulties in coping with the situation. However, looking at the level of preparedness, the capacity of health system of Pakistan was not even ready to be challenged for such pandemic. Probably health ministry had not followed the WHO earlier guidelines issued in 20178 & 20189 regarding influenza risk and impact management as well as capacity building for such pandemic response. It was very likely for Pakistan to get the COVID-19 cases as it shared the borders with China & Iran, countries with very high number of COVID-19 cases and deaths. Pakistan’s first-line response of closing borders with China and Iran was a very positive step. Later on, travels restrictions were imposed on all international & national flights, train services and inter-city transport as well. Closing education institutions, public offices, markets and restrictions on religious congregations were the main steps taken by the government. However, overall response of political leadership can be labelled as “confused response”.10 Federal and provincial governments were not on the same page regarding complete lock-down, leading to partial lock-down and later on to the controversial “smart lock-down” due to severe economic pressure. Lack of public awareness, "infodemic" of incorrect information, myths, propaganda and conspiracy theories about COVID-19, mishandling the newly diagnosed patients or their families and dealing with dead bodies of COVID-19 patients led to a distorted public response for COVID-19. Government could neither convince the public about maintaining social distancing nor enforce the standard operational procedures suggested for easing the lockdown. This proved to be a disaster, leading to a surge of new cases across the country. WHO’s Head of Mission in Pakistan criticised the decision of lifting restrictions in a letter on June 07, 2020 and advised the local authorities to re-impose the lockdown.11 Preparedness for surveillance, investigation and assessment of COVID-19 cases was very low in Pakistan. Daily testing capacity of Pakistan for COVID-19 was 6584/day12 on April 07, 2020 and increased to 16414/day13 on April 28, 2020. However, with over six thousands new cases per day, testing capacity needs to be increased several folds. Other areas of major concern are risk and severity assessment, health services provision & clinical management of severe cases. Government of Pakistan established several quarantine centers in major cities of Pakistan as well as near Pakistan-Iran & Pakistan-Afghan borders to prevent the spread of the disease. Majority of COVID-19 patients with mild to moderate severity were effectively managed in all clinical settings of the country. However, the major issue observed during the clinical management of severe COVID-19 patients was lack of intensive care facilities and high dependency units across the Pakistan. Lack of trained human resources (e.g. intensivists and paramedics), shortage of appropriate medical devices like ventilators, interrupted supply of essential medicines including central oxygen supply, non-availability of important investigations like D-Dimers, CT chest etc. in majority of health-care settings and absence of local guidelines for management of serious patients exposed the existing health-care services provision of Pakistan. Government, however, encouraged the research on covid-19 patients and few clinical trials are in progress. Response of health-care providers for covid-19 was exemplary and despite lacking appropriate personal protective equipment, they served with dedication and professionalism. A very large number of health-care providers contracted COVID-19 during service provision and unfortunately, a significant number of doctors, paramedics and nurses died due to COVID-19. This adversely affected the clinical management and recovery process of the COVID-19 patients. Maintaining the essential services and monitoring of commodity prices is vital in such pandemic situations. Unfortunately, price hikes of essential drugs, petrol and flour crises and economic crises showed poor control and response of government during this critical time. Overall, preparedness and response of Pakistan in anticipating, preventing, detecting, managing and controlling the COVID-19 outbreak was suboptimal. It is highly suggested that government authorities may revisit the national action plan for COVID-19 to identify the gaps and cope with the new challenges. Pakistan needs to increase the share of the nation's Gross Domestic Product on health spending not only to ensure excellence in clinical services but also to strengthen the public health system of Pakistan.

PREPAREDNESS AND RESPONSE OF PAKISTAN FOR CORONAVIRUS DISEASE 2019: GAPS AND CHALLENGES