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Pakistan’s health system rests on two financing channels that are not interchangeable. Public budgets are personnel-heavy and fixed, financing salaries, facilities and routine operating costs. Official Development Assistance is flexible and commodity-heavy, financing the vaccines, diagnostics, supply chains, surveillance and specialist staff that vertical disease programmes depend on. With global ODA now contracting sharply and grants falling to just 4% of total flows to Pakistan, the consequences are functional rather than fiscal. The 2025 USAID suspension closed over 60 facilities and disrupted care for 1.7 million people; a USD 27.2 million Global Fund reduction halved TB monitoring in two provinces and placed treatment for over 42,000 HIV-positive patients at risk. These are not system-wide collapses but precise ruptures in the functions external financing has long underwritten.

This report maps how the contraction is transmitting through the system and sets out a structured transition agenda for federal and provincial governments built around foundations, response and delivery.

Authors: Behzad Taimur, Shahab Siddiqi and Syeda Farwa Qamar Jaffri

Research: Asbah Asif
Review: Umar Nadeem
Design: Maryam Afeefa

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Pakistan’s mobile internet use among women is the highest in South Asia — yet female labour force participation remains among the lowest. Why does this gap persist?

Tabadlab’s latest series draws on a bespoke research suite to unpack how women in Pakistan access, use, and navigate digital technology in their everyday lives and work environments.

Access to Agency: Gender, Work and Mobile Connectivity in Pakistan explores:

• Gendered differences in mobile ownership, internet use, digital payments, and online safety
• How women build resilience and navigate professional and digital spaces that are often not designed with them in mind

The four-part series combines women’s voices from the field with data-driven insights.

Explore the series:01. Series Introduction: From Access to Agency. How do Women Navigate Technology and Work in Pakistan?

1. ⁠Access, Ownership and Use of Mobile Technology for Urban Women in Pakistan

2. ⁠Cell Phone Usage: How do Urban Women Navigate the Online Space and Manage Harassment

3. Women at Work: Stories Behind the Statistics

From Access to Agency: How do Women Navigate Technology and Work in Pakistan?You can download the full report here.

View Fullscreen × Access, Ownership and Use of Mobile Technology for Urban Women in PakistanYou can download the full report here.

View Fullscreen × Cell Phone Usage: How Do Urban Women Navigate the Digital Space?You can download the full report here.

View Fullscreen × Women at Work: Stories Behind the StatisticsYou can download the full report here.

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Pakistan’s public education system faces a persistent and often misunderstood challenge: not simply a shortage of teachers, but an imbalance in how teachers are deployed across schools. The Missing Ustaani presents a province-wise analysis of teacher availability using the 2022-23 Annual School Census data, with a particular focus on primary and middle schools with girls’ enrolment. Although Pakistan has adequate sanctioned teaching posts as per an STR 30 benchmark, 195,550 positions remain vacant, resulting in an effective shortage of over 63,294 teachers in classrooms. This contributes to overcrowded classrooms, widespread single-teacher schools, and persistent inequities that disproportionately affect girls. To capture the environments where these pressures are most acute, the report also introduces a measure of “critical shortages”, identifying schools that not only exceed acceptable student–teacher ratios but also lack basic facilities such as toilets or safe drinking water. This combined burden highlights environments where both staffing and basic infrastructure fall short, compounding the barriers to effective teaching and learning. By reframing Pakistan’s teacher shortage as a workforce imbalance rather than a numerical deficit, The Missing Ustaani emphasises the need for data-driven deployment, improved teacher management systems, and targeted strategies to ensure that every child, especially every girl, is taught by a qualified teacher in a safe and functional learning environment.

Authors: Fahad Zafar, Muhammad Bilal Kakli, and Zaina Shahab

Research Team: Roha Afaq and Sajjad Hussain

Review and Editing: Shahab Siddiqi and Umar Nadeem

Design: Eman Sarwar

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Trump’s Liberation Day Tariffs

| – The era of open trade is ending. Countries with large home markets, strong trade fundamentals, and/or significant diplomatic capital may be able to take advantage of the opportunities that the Trump administration’s tariff increases present. However, Pakistan has historically struggled in such scenarios. Without urgent and strategically coherent policy actions, this moment could become more risk than opportunity for the Pakistani economy.– Our estimates suggest that Pakistan’s export loss will amount to approximately USD 564 million in FY 2025-26 under the new US tariffs—potentially increasing to over USD 2 billion over time in the worst-case scenario. This would negatively impact the current account deficit, undermining recent progress and compounding the country’s fragile economic growth outlook.– The textile sector—the backbone of Pakistani exports—is most at risk. As the largest export market for Pakistani textiles, the US may continue to offer opportunities as exporters from competing countries (such as Sri Lanka, Bangladesh, Vietnam and Cambodia) face even steeper tariffs. However, US consumers are price-sensitive: a 29% rise in export prices will slash demand by at least 13% by 2025-26.– Pakistan’s imports from the US are small in magnitude and generate limited tariff revenue—only USD 85 million in FY 2023–2024. While Pakistan imposes some sector-specific duties, US exporters generally do not face any exceptional barriers to entry. For American policymakers, tariff tweaks alone won’t meaningfully increase exports to Pakistan. |

In a ceremony he anointed as “Liberation Day”, President Donald Trump announced a new tariff regime for exports destined for the United States. A wide array of countries that compete with Pakistan for US imports now face significantly high tariffs as a result, including Vietnam (46%), Cambodia (49%), Bangladesh (37%), Sri Lanka (44%), China (34%), Thailand (36%), and Taiwan (32%). The new tariff regime will impose an average tariff rate of 29% on Pakistani exports to the US.

The Trump administration’s actions are consistent with the president’s campaign promises as he seeks to reshape the US economy—using American strategic, economic and military strength to force the adoption of new trade terms by US trade partners. The inflationary impact of tariffs or other considerations consistent with neoliberal economic theory are of limited consideration for the Trump administration as it seeks specifically to reduce the quantum of US dependence on external supply chains, and reduce the leverage accumulated by countries that enjoy trade surpluses with the American economy (especially China).

This document is restricted to the analysis of the potential economic implications of the new US tariff regime on Pakistan’s economy. It is based on analytics provided by Tabadlab’s proprietary ‘Datacube’ analytics and insights tool.

Snapshot of the US-Pak trade

America’s share of Pakistan’s major imports is very low

Pakistan’s effective tariff rates to the US are lower than overall average. In 2024, Pakistan collected USD 3.9 billion in tariffs on total imports of USD 47 billion—an effective tariff rate of 8%. In contrast, US imports, totaling USD 1.8 billion, generated only USD 85 million in tariffs, indicating a lower rate of 4%.The US claim of a 58% average tariff rate appears inconsistent with these figures, even when accounting for para-tariffs (such as regulatory duties, sales tax, FED, and income tax collected at source), which are not traditional customs duties.

Tariff protection and para-tariffs

Certain sectors benefit from high tariff protection and para-tariffs. For example, vehicles face an effective tariff rate of 76%, one of the highest among import categories.

Pakistan’s weak tax collection machinery at a domestic level also forces the government to charge value-added tax (18% in general but as high as 25% in some categories like automobile imports) and income tax at source, especially on consumer items. Similarly, the country extensively uses para-tariffs like regulatory duties to manage consumption of luxury items which are not applied to domestic produce. This may represent an area of weakness in negotiations with the US because other countries may not have similar charges applied to imports at the port. Taken cumulatively, for policy makers, this makes the narrative of fair tariffs a more challenging sell.

Pakistan’s Non-Tariff Barriers

Non-tariff barriers might emerge as a potential point of friction in US-Pakistan trade relations. Examples include the use of SROs (Statutory Regulatory Orders) to manage specific import items and restrictions on US digital platforms like X (formerly Twitter). These issues have been noted in the Foreign Trade Barrier report published by the US Trade Representative’s (USTR) office, and referenced by President Trump.

While the USTR report does not accuse Pakistan of targeted barriers against the US, nor of currency manipulation, it signals areas of concern. To mitigate future tensions, Pakistan must proactively engage with US counterparts and manage these perceptions carefully.

Scope for Change in Current and New Sectors

Pakistan already offers American businesses a decent market access in areas such as cotton where there is zero tariff and where the local market offers significant scale such as animal and vegetable fats (USD 3.5 billion in total imports). There is limited scope to offer tariff related benefits in these areas.

The US is not a significant exporter of goods that Pakistan requires on a regular basis and the US government is looking to change this. Whilst difficult to achieve in the immediate term, Pakistan has strategically offered FTAs to countries like China, Turkey and Sri Lanka and this has significantly improved access of goods of these countries to Pakistani consumers. Some significant sectors in which the US currently exports goods but faces significant tariff protection in Pakistan include: Vehicles (76% tariff on USD 1,234 m imports), Furniture (27% tariff on USD 91m imports) Edible fruits and nuts (22% tariff on 122m imports) and Paper (19% tariff on 408m imports). Any change on this front would require Pakistan government to change its sector policy.

In the near term, Pakistan has more flexibility to expand access for US firms in the services sector—particularly in digital payments. With a growing market estimated at USD 35 billion, this space remains largely untapped by US players. Google has recently entered the Pakistan market through the launch of Google Pay in Pakistan, marking a potential shift in the landscape—other similar entries, facilitated by enabling public policy, may be seen favorably by US negotiators.

Favorable Terms of Trade with the US

Pakistan enjoys favorable trade terms with the US, generating nearly USD 400 million per month in current account surplus, alongside an average of USD 300 million a month in remittances. In recent months, Pakistan has exported nearly USD 500 million per month in goods and over USD 250 million in services to the US. Whilst significant for Pakistan, they amount to just 0.16% of the overall annual USD 4 trillion US imports.

What Trump’s Tariffs mean for Pakistan

Lifeline of Pakistani textile exports sector

While tariffs will impact all sectors, textiles account for over half of Pakistan’s exports to the US, making this sector particularly vulnerable. Initial discussions with exporters indicate that the sector’s low profit margins make it difficult to absorb increased costs and US importers are likely to pass these costs onto US consumers. This could lead to a reduction in the volume of textile imports into the US. However, there is no immediate solution to manufacturing these goods domestically in the US. Whether Pakistan will lose or gain market share in the US will largely depend on how the Pakistani government engages with the Trump administration and how other textile-producing countries respond. Rapid and proactive engagement with US authorities, such as what Vietnam’s government is doing, are likely to yield the best results.

Market Share

Although the proposed tariff increases are unlikely to reduce Pakistan’s market share significantly in the short term, the dynamics could shift as other countries renegotiate their trade terms with the US. Competitors such as India, Bangladesh, and Vietnam face similar or higher tariff hikes, potentially keeping Pakistan’s share stable—or even allowing it to grow. Nonetheless, given that these competitors operate with larger trade volumes, their negotiations could have a greater impact on US policymaking and market outcomes.

Reduced Demand for Imports in the US

In the long run, higher tariffs are likely to reduce demand for all imports into the US, including Pakistani goods. Studies indicate that the price elasticity of US imports is around -0.2 to -0.5 up to a year, and -1.67 in the long term. This means that a 10% tariff increase would lead to a 5% reduction in demand by 2026 and 17% in the medium to long run.

This will affect Pakistan’s exports in two key ways.

• Impact on Exports of Goods: Our internal forecast currently suggest a target of USD 42.5 billion for exports for Pakistan including USD 6.3 billion in US exports of goods. With a 29% increase in tariff for US consumers, we estimate a loss of approximately USD 564 million in the base case and USD 2,166 million in the, unlikely, worst case where we lose market share and domestic demand in the US is increasingly met by local producers. This will erase the recent gains in exports in all the sectors but will particularly impact the textile sector.
• Impact on Exports of Services: A significant portion of Pakistan’s export growth is in services which have increased from an average of USD 200m in 2023 to USD 250m in 2024 and beyond. This sector will not be affected by tariffs per se but may become an avenue of conversation in negotiations.

What Pakistan needs to do next

Initiate New Trade Negotiations

• Initiate (or accelerate) negotiations for new bilateral trade agreements—not just with the US, but also with economic blocs like the GCC, ASEAN, and RCEP
• Revisit existing trade agreements, especially those with high risk of producing adverse outcomes such as dumping into the Pakistani market

Build Data-Driven Trade Capacity

• Expand and deepen government capacity to collate and analyze key economic data
• Invest in human capital and tools to monitor and respond to shifting trade dynamics globally
• Ensure that decision making for domestic and foreign trade policy is informed by data

Reform the Tariff Regime

• Reassess the basis for the existing Pakistani tariff regime, including the risks of using tariffs as a source of foreign currency denominated revenue
• Eschew the use of para-tariffs, import taxation, and protectionist policies—especially in inefficient sectors
• Deploy tariffs more strategically, in service of national objectives, rather than allowing tariffs to be used in service of narrow interest groups—such as inefficient and low quality domestic vehicle manufacturers

Enhance Economic Diplomacy

• Build a stronger international trade negotiation team with sectoral expertise. Consider the merger of the Commerce and Foreign Service occupational groups of the civil service as a necessary element of developing such expertise
• Revisit existing silos and dual functions across the federal government, such as the divide between Commerce and Foreign Affairs divisions, or the duality of the Trade Development Authority of Pakistan, and Pakistan Software Export Board

Diversify and Upgrade Export Offerings

• Invest in non-substitutable, complex products to gain a competitive edge

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BackgroundPakistan is currently pursuing its 24th IMF bailout package to facilitate long-term reforms. The agreement aims to unlock USD 1.1 billion from the IMF’s USD 3 billion standby arrangement from the previous year. Reforms will primarily target fiscal consolidation, energy sector viability, inflation, and private sector-led economic activity. The 65th Tabadlab Policy Roundtable unpacked the implications of this programme for Pakistani citizens.

Featured Panelists

Hadia Majid

Hadia Majid is an Associate Professor and Economics Department Chair at LUMS.

Tobias Haque

Tobias Haque is the Lead Country Economist for Pakistan at The World Bank.

Sobia Khurram

Sobia Khurram is a Professor at the Institute of Administrative Sciences at the University of Punjab.

Shahrukh Wani

Shahrukh Wani is an Economist at the International Growth Centre and has experience working in Afghanistan, Pakistan, Uganda, and Zambia.

Khurram Husain

Khurram Husain is a Business and Economy Journalist and writes regularly for Dawn.

Discussion SummaryTax Reform and Fiscal Consolidation

Pakistan’s persistent failure to reform its tax base and power sector has emerged as a significant hurdle in negotiations with the IMF. The complexity of the tax system, coupled with distortionary exemptions, undermines its capacity to generate revenue. Addressing these structural deficiencies is important to ensure economic growth and stability. A unified tax system with minimal exemptions could broaden the tax base and improve revenue collection. Moreover, leveraging data-driven approaches, as exemplified by Kenya, India, and Ghana, can improve transparency and enforcement capacity in tax administration, and ensure accountability.

Governance and Policy Implementation

The efficacy of Pakistan’s reform efforts hinges on effective governance and policy implementation. The lack of consensus and unity within the government impedes the execution of reform policies and undermines its credibility. Strengthening collaboration among government agencies and stakeholders is essential to drive greater support for reform. Moreover, aligning IMF programmes with the broader government agenda, and ensuring accountability in policy execution, is critical for achieving outcomes and restoring investor confidence.

Structural Sector Reforms and Economic Competitiveness

Pakistan’s economic challenges are deeply rooted in structural deficiencies. This demands comprehensive reforms to improve productivity and market competitiveness. The complexity of the tax system and reliance on indirect taxes inhibit economic growth and investment. Addressing rent-seeking behaviour among the business elite and promoting inclusive growth is imperative for unlocking Pakistan’s economic potential. As with successful reform trajectories in countries like India, South Korea, and Malaysia, targeted reforms in key sectors such as manufacturing, textiles, and agriculture can drive economic transformation and job creation.

Social Protection and Inclusive Growth

Alongside efforts to reform the economy for greater fiscal sustainability, it is equally necessary to safeguard the welfare of vulnerable and marginalised groups. Pakistan’s regressive fiscal system exacerbates income inequality and social disparities. Introducing targeted social protection measures and expanding the tax base through direct taxation can improve revenue generation while ensuring a more equitable distribution of the tax burden. Moreover, investing in human capital development and inclusive growth initiatives can mitigate the adverse impact of reforms on vulnerable communities and promote inclusive economic development.

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Existing discourse on women’s relationship with technology centres itself on paradigms of accessibility and ownership; however, a series of early conversations with women in Pakistan revealed more nuanced and personal contours within that relationship. These shape how women understand, interact, and adopt technology. We explore the subtle behavioral, perception-based, and emotive specificities ranging from fear, guilt, and self-doubt, as informed by socio-cultural experiences and beliefs that characterise women’s interaction with technology.Through our work, we hope to deepen the understanding around women’s contextual realities that are critical in shaping successful digital interventions aimed at improving digital adoption at scale.This was presented by Tabadlab at the Global Digital Development Forum 2023. Watch the video here:Read the deck: Download File View Fullscreen × The post Decoding the Subtleties of Women’s Relationship with Technology appeared first on Tabadlab | Understanding Change.

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Applying Behavioral Insights to Activate Parental EngagementYou can download the full deck here.Education outcomes in Pakistan are characterised by a twin crisis – a high number of children do not attend school, and those in school do not learn at the requisite level. This chronic stagnation of outcomes makes Pakistani children one of the lowest performing cohorts in the region. In a hyper competitive, rapidly changing, and increasingly integrated world, these low education outcomes are a dire threat to the progress and well-being of Pakistani children and the vitality, prosperity and standing of the country as a whole.The longevity, diversity and complexity of the learning crisis in Pakistan warrants unpacking this area of national importance with much greater rigour. In addition to understanding structural and supply-side issues, it is vital to try to explore the why, the who and the how of learning in Pakistan. To do so, we have employed behavioral science insights to diagnose factors that can help redesign the learning equation—not just in Pakistan but far beyond.

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Pakistan’s Debt CrisisYou can download the complete PDF here.Detailed in Tabadlab’s seminal analysis, “A Raging Fire,” the gravity of this crisis is laid bare, revealing the depth and breadth of the problem, the quantum of financial resources lacking, and the path forward with or without transformational structural changes.

By dissecting key financial indicators, drawing comparisons with global standards, and showcasing multi-scenario projections “A Raging Fire” serves as a critical blueprint for navigating Pakistan’s debt dilemma.

Providing comprehensive solutions in a dedicated section, the analysis ends with crucial reforms needed to extricate Pakistan from the this perennial financial spiral, and put it on a path to economic recovery, eventually leading to prosperity.

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How Fintech is transforming Saudi ArabiaYou can download the full deck here.Since 2018, fintech in Saudi Arabia has achieved staggering growth in a way that promises to transform the country and its position in the global economy.

This shift was enabled by a successful policy effort, but the scale of growth has exceeded goals and expectations. What does this transformation look like? What does it mean for the country’s economy and society? What lies ahead for Saudi Arabia in the face of this tremendous shift?

“Vast, Fast & Ahead of Schedule” tells the extraordinary financial transformation story of Saudi Arabia, and the world should be paying attention.

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You can download the PDF version here. Pakistan has witnessed a high...

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Download the full report PDF (20 MB) Download the executive summary (6 MB)Digital technologies are reshaping the global economy in unprecedented ways, especially since the accelerated adoption of digital during Covid-19. This structural shift in how individuals, businesses, governments, and societies interact has deep-rooted implications for politics, labour markets, trade, governance, and human rights.For Pakistan to keep pace with the evolution of the global economy, it needs to undergo a radical, multi-sectoral digital transformation that requires an ambitious and forward-looking agenda. Tabadlab’s Digital Now: A Guide To Pakistan’s Digital Transformation outlines this agenda in a comprehensive vision for a truly Digital Pakistan.Download the full report PDF (20 MB) Download the executive summary (6 MB)The post Digital Now: A Guide to Pakistan’s Digital Transformation appeared first on Tabadlab | Understanding Change.

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ContextOn November 28, 2022, the Foreign Office of Pakistan announced that Minister of State for Foreign Affairs Hina Rabbani Khar would visit Kabul. Her delegation included Special Representative of Pakistan to Afghanistan, Ambassador Muhammad Sadiq and officials from the ministries of commerce and finance.[1] The purpose of the visit was to improve bilateral relations, and especially trade – given Pakistan’s stated priority to alleviate the severe economic pressure faced by the people of Afghanistan.[2]

Almost simultaneous to the announcement of the Khar visit to Kabul came the Tehrik e Taliban Pakistan’s (TTP) statement that it was ending the so-called indefinite ceasefire it had claimed to agree to in June 2022.[3] With the formal announcement of what was, in effect, a scaling up of its terrorist activity in Pakistan, the TTP said, “As military operations are ongoing against mujahideen in different areas, … so it is imperative for you to carry out attacks wherever you can in the entire country.”

Four days after the announcement ending the ceasefire, terrorists attacked the Pakistan embassy in Kabul[4] targeting the Pakistani head of mission, Ubaid-ur-Rehman Nizamani. Mr. Nizamani survived the attack, having taken charge of the Pakistan embassy in Kabul only four weeks prior.[5] In addition to strongly condemning the attack, Pakistan’s Foreign Office announced that the Government of Pakistan and the interim Afghan authorities were working closely to determine the veracity of the Islamic State in the Khorasan Province’s (ISKP) claiming of the attack.[6] ISKP has deep linkages with the TTP,[7] predominantly through their co-location in Afghanistan.

Although the Islamic Emirate of Afghanistan (IEA) have condemned the attack, and ISKP has claimed responsibility for it, a terrorist attack on the lead Pakistani diplomat in Afghanistan so soon after the end of the TTP’s so called ceasefire raises serious questions in Islamabad. International outcry and condemnation of the attack has been largely muted, especially given the high rank of the Pakistani diplomat in question and the wider implications of a terrorist attack of this nature. Though not overtly related to these events, the new Chief of Army Staff (COAS), General Asim Munir, issued a statement declaring the military’s willingness to reengage in kinetic operations to protect civilians from the threat of terrorism.[8]

Negotiations and CeasefiresFor all intents and purposes, the ceasefire was null and void for months, and the announcement on the 28th of November simply formalised that – but the escalation in violence makes it apparent that the formal end to the ceasefire has enabled TTP to declare open season across the country.

The history of Pakistan’s negotiations with the TTP, ceasefire agreements, and other political concessions is quite clear. The end of the latest so-called ceasefire[9] represents the latest in a long series of attempts[10] by Pakistan to find alternatives[11] to military action against the TTP – efforts that are fifteen years old, tracking all the way back to 2007. Negotiations have nearly always failed, despite the Pakistani state offering a range of concessions, including involving tribal leaders in the conversation, releasing TTP prisoners, and repatriating terrorists’ families. The TTP has consistently used negotiations to normalise anti-state discourse – demanding measures that effectively equate to the dismantling of the Pakistani republic.

Traditionally, ceasefires have been leveraged not as tools of violence-mitigation, but to buy time. For the TTP, it allowed for regrouping, stocktaking, and strengthening. For the Government of Pakistan, ceasefires have been seen as a way to generate respite for frontline forces, and allow for strategy assessment, and redeployments, as well as the application of political pressure. For fifteen years – efforts to negotiate politically with a violent extremist group that employs terrorism as its primary instrument of politics – has only resulted in the weakening of the Pakistani position, and an eventual return to violence. The latest ceasefire episode has been no different.

Past Efforts: Containment and ManagementAt a cursory glance, one could make the argument that trying to negotiate with a banned, violent, anti-state group indicates that the Pakistani state has not been able to implement its writ upon its sovereign territory. However, the circumstances of this set of negotiations and the short-lived ceasefire are more complicated than that.

First, the TTP and its leadership is no longer in Pakistan. The estimated 5,000 or so fighters of the TTP reside primarily in the bordering provinces of neighbouring Afghanistan.

Second, while Pakistan has the air capability to target TTP hideouts in Afghanistan, it does not have the foot intelligence to mitigate civilian casualties, and any cross-border air strikes would result in further alienating an increasingly distanced Islamic Emirate of Afghanistan (IEA).

Third, a ceasefire is also a mechanism to provide temporary relief – both to the active troops on the ground, and the civilian populations that have suffered nearly two decades of violence – particularly in the NMDs and wider Khyber Pakhtunkhwa.

How has the TTP survived?The obvious question is: why, after the concerted and highly successful Zarb e Azb military campaign of 2014, was the TTP allowed to survive and eventually coalesce in 2019 to form the group as it stands today?

First, under tremendous pressure from the concerted kinetic military and intelligence operations, the group splintered into multiple factions and scattered across various geographics, on both sides of the Pakistan-Afghanistan border. This made it very difficult to target and eliminate its members, track down its leadership, and shut down its operations entirely.

Second, the Doha pact[12] signed on February 29, 2020, between the Trump administration and the Afghan Taliban (notably without any representation of the Ghani regime) created legitimacy for the Afghan Taliban. This had significant knock-on effects on the Afghan Taliban morale (in terms of their recruitment, and consolidation of assets and power), and emboldened affiliated groups, as well as the TTP. Combined with the drawdown announcement in April 2021,[13] and a reiteration of this promise in July 2021,[14] this further accelerated the Afghan Taliban’s campaign, which was already sweeping across the country and eventually resulted in the takeover of Kabul on August 15, 2021.[15] By extension, the recently re-coalesced TTP[16] also felt empowered, considering its allegiance to the Afghan Taliban.

Third, shortly after the takeover of Kabul, the IEA also released hundreds of TTP fighters[17] from various prisons, including founding deputy emir Maulvi Faqir Muhammad. The TTP was also given complete freedom of movement and operations, and its emir Noor Wali Mehsud renewed its pledge of allegiance[18] to the Afghan Taliban. The TTP had a significant base in Afghanistan that was only bolstered and further legitimised by the prisoner release. While the two have coexisted physically, and operationally intertwined against international forced, the Afghan Taliban have never actively encouraged attacks inside Pakistan.

Fourth, the release of prisoners is a negotiation tactic between the Government of Pakistan and the TTP. In November of last year, the TTP demanded the release of its fighters[19] as a pre-condition for talks. This demand was met by Pakistani authorities, and up to 100 TTP prisoners were released[20] in early December 2021, and again[21] in May 2022. While this is a diminishing resource, given that an emboldened TTP had carried out attacks killing hundreds in Pakistan since August 2021, allowing known enemies of the state to escape the rule of law, is of questionable utility.[22] A related question here is why captured members were not tried, prosecuted, and sentenced at the scale needed to establish the writ of the state, despite a carte blanche being given to the military courts under the NAP.[23]

Fifth, the Pakistani state’s historic insistence on viewing certain groups, especially the Afghan Taliban, as a strategic compulsion, complicates its ability to rationally negotiate with a group allied to them but opposed to the Pakistani people and Pakistani state. Former Prime Minister Imran Khan went so far as to say that the only solution to the TTP problem was a political settlement.[24] Adding to the confusion was the claim by President Arif Alvi and the former PM that an amnesty was on offer if the group laid down its arms. A military spokesperson also confirmed[25] that the recent (now failed) talks and ceasefire was requested by the IEA, emphasising Pakistan’s blind spot when it comes to the Afghan Taliban leadership.

Who will be the likely targets?While the end of the ceasefire has been declared as a consolidated effort against the state of Pakistan, in practical terms, this means an increase in attacks and violence in the NMDs, Khyber Pakhtunkhwa (particularly Swat, Upper Dir, and Lower Dir), and the Quetta Block (comprising of districts Quetta, Pishin, Killa Abdullah).

Given historical precedents and the souring of public opinion against the TTP, particularly after the APS attack, it is unlikely that they will purposely target civilian populations and installations. The bulk of the terror attacks will likely be conducted against security forces in the border and adjoining areas, particularly less-defended security check posts, border outposts, and patrolling convoys. It also follows that a greater volume of attacks will result in an escalation in counter-terrorism operations as well.

What are some factors influencing the situation?Patronage from the Afghan Taliban: Members of the TTP – estimated to be around 5,000 within Afghanistan, with patronage, support, and freedom of movement for their members – reside in provinces bordering Pakistan, particularly Kunar, Khost, and Paktika. They are well-organised, equipped, trained, and mobile. This patronage from the Afghan Taliban regime, in direct violation of the Doha agreement, will likely continue. Having deep roots in Al Qaeda and connections with the Islamic State in the Khorasan Province (ISKP), the IEA would be keen to keep the significant TTP presence appeased and in check, rather than having them turn on them, or worse, join the ideologically opposed ISKP. While negotiations between Pakistan and the TTP occurred at the facilitation and behest of the IEA, with no resolution and the lifting of the ceasefire, the IEA is now in a very precarious and unenviable position.

The Pakistan-Afghanistan relationship: Another factor is the ability for Pakistan to leverage its relationship with the IEA, and the impact that may have on the internal dynamics of Afghanistan. A day prior to the announcement of the end of the ceasefire, the Pakistan Foreign Office announced that Minister for State Hina Rabbani Khar would be visiting Kabul.[26] This inevitably also changed the ensuing dialogue to be more security-focused, with emphasis placed on curbing cross-border attacks on Pakistani security forces, as well as mitigating the movement of armed fighters across the fenced position. Following the attack on Pakistan’s head of mission in Kabul, the Foreign Office issued a statement demanding that “the interim government of Afghanistan must immediately hold thorough investigations in this attack”[27] and hold culprits to account. In response, the IEA has also issued a statement condemning the attack and assuring a “serious investigation,”[28] but the tangible consequences remain to be seen. Over time, Pakistan’s relationship with the Islamic Emirate, both in terms of its perceived leverage over the group, and the Emirate’s willingness to accommodate Pakistani demands, has been increasingly grounded against its own internal risk matrix.

Border dispute: The border between Pakistan and Afghanistan continues to be a thorny issue and has been politicised to suggest that Pakhtuns on both sides believe it to be a barrier to their long-standing ties and mobility. This may be true for the Afghan side, but it is not necessarily the case on the Pakistani side. It is also a contentious issue for the Afghan authorities, given the several[29] border[30] skirmishes[31] that have broken out[32] along[33] the fenced position, often resulting in closing of border crossings.[34]

TTP’s operational capacity: Assessing the access and capability of the TTP – both the released fighters within Pakistan, and the bulk of its operational forces in Afghanistan – is a key consideration. Pakistan’s security apparatus needs to do better in terms of building local trust and buy-in, as well as establishing stronger foot intelligence to aid in early warning and prevention.

Pakistan’s economic and political crisis: Pakistan is also facing a range of internal political and economic crises. The country is going into an election season with political rivalries and acrimony at an all-time high, thereby affecting political priorities and focus. In addition, after six years, the Chief of the Army Staff (COAS) was appointed[35] a few days prior to the annulment of the ceasefire. This has implications both in the context of the prioritisation of national security in the face of the TTP threat, and how the military establishment works with the civilian government to tackle the long-standing TTP puzzle.

Centre-province divergences: The federal-provincial divide in Pakistan has historically resulted in political point scoring and blame gaming, instead of broad collaboration to tackle the many challenges, particular in the Khyber Pakhtunkhwa and the tribal regions. Over the course of time, PTI’s strong popularity in the region and the party’s alienation from the military after the change in government in Pakistan in April 2022 has resulted in significant challenges for the alignment between the security sector and the wider public and political discourse.

Seasonal capability: One factor that limits the TTP’s ability to strike targets is the onset of the winter season. There is sufficient historical evidence to suggest that the ferocity and frequency of attacks lessens in the winters. However, given that the end of the ceasefire was announced at the end of November, the TTP has also conducted attacks to establish legitimacy, tactical prowess, and strike capability.

What does Pakistan need to do?The TTP in December 2022 represents an urgent national security challenge for Pakistan. Small groups or “tashkeels” have been infiltrating through Dir for years. This time, ostensibly buoyed by the Pakistan-TTP talks, these armed members have stayed – leading to local populations pushing back through several protests in the region.[36] Any TTP terrorists on Pakistani soil pose a clear and present danger to society, the state and the security sector in the region. In the absence of effective elimination, apprehension, or movement restriction, these terrorist “fighters” (more than one hundred of whom were recently released[37]) are an immediate problem. The fighters residing in Afghanistan constitute the next priority or group of concern.

Pakistan’s TTP problem has been decades in the making, and has now lasted for fifteen years. It is clear, both through historical precedent and the obduracy of the TTP, that a political settlement or permanent ceasefire are not an option. Given the violent attacks over the last fifteen months, despite the so-called ceasefire, the group has signalled its intent to inflict damage and continue to undermine to undermine the Pakistani republic, particularly in the newly merged tribal districts regions bordering Afghanistan.

Containment, management, and the eventual cycle of negotiations and ceasefires needs to be catalogued as ineffective and shelved as a serious option for Pakistan. The country has suffered tremendously at the hands of terrorist groups in the last two decades, and all prior attempts at reconciliation, political settlement, or ceasefire have failed, save the temporary reduction in hostilities that these agreements offer.

A major shift in thinking is overdue, one that is mandated by both the 25th Constitutional Amendment and the very pronounced public outcry against the TTP resurgence over the last three years. Pakistan’s political and security sector need to better respond to the needs and demands of right-based movements like the Pashtun Tahaffuz Movement, and forge better political buy-in from local communities that are most deeply affected by the TTP’s violence. Policies, postures and politics that causes the alienation and disenfranchisement at the grassroots is a formula for an ever growing TTP footprint and expanding distance between Islamabad and the people. The strong public sentiment against the group needs to be channelled and responded to by the state, rather than undermined or propagated against.

What Pakistan must do internally:

1. Identify, stop, and prosecute terrorists by mandating and empowering civilian law enforcement, administration, judicial bodies. This needs to be the de facto state policy with two caveats:
   1. First, any prisoners of this conflict must be treated following the stipulations of the Geneva Convention[38]
   2. Second, effects on the local population must be accounted for, and efforts made to shield them from displacement or disruption in livelihoods
   3. Third, there is no tactical reason for not offering amnesty to terrorists that lay down their arms, but it must be accompanied with the application of the rule of law to said individuals. This can be an easy step toward splintering group cohesion and obtaining updated intelligence from surrendering terrorists.
2. Vigilantly monitor, patrol, and control the now-fenced border, with clear rules of engagement established with border control authorities and governments on both sides. Border posts are likely to remain easy and primary targets for inflicting damage, and non-crossing sections for attempting infiltration. Pakistan has been fencing the border for nearly six years, with 94% of the work complete by January 2022,[39] and has maintained for a long time that the border is a settled issue.[40] However fencing must be 100% complete for this to be an effective tool.
3. Heighten security in sensitive installations across the country, but particularly in the newly merged districts and other adjoining areas
4. Enhance, develop and renew foot intelligence or human intelligence networks, building confidence with the local This is necessary both to thwart the potential recruitment of marginalised communities (particularly youth) by the TTP, and to provide actionable information and intelligence to pre-empt potential terrorist planning and attacks.
5. Cross-border military operations, such as the airstrikes conducted earlier this year are the least desirable option. The previous airstrikes, which reportedly killed at least 47 civilians in Afghanistan April 2022,[41] had limited tactical applicability and negligible strategic value. If anything, it weakened Pakistan’s position in the negotiations with the TTP facilitated by the Afghan Taliban government. Airstrikes also draw the ire of the Afghan Taliban and the international community, particularly since the April strikes came under severe criticism by both the UN and the public in Afghanistan.[42]
6. The release of TTP prisoners as a tool for negotiation and a confidence building measure is a diminishing resource with limited efficacy. Pakistan needs to properly prosecute TTP prisoners and use the resulting justice as a deterrent and a signal of the state’s strong intent and will to pursue and punish terrorists.

What Pakistan must do regionally:

Diplomatic

1. Apply pressure on the Islamic Emirate of Afghanistan (IAE) to keep the TTP in check and restrict its movement across the border. This is problematic because a) the TTP has sworn allegiance to the Afghan Taliban, and b) their raison d’etre is to conduct terror operations against the Pakistani state and security forces, supporting the IEA, and the eventual imposition of their version of Shariah law in Pakistan.
2. Think beyond the carrot and stick approach of pushing for the repatriation of Afghan refugees, tightening of the visa regime, and border closures as effective policy instruments to coerce the IEA. These interventions only result in further alienation and resentment of ordinary Afghans.
3. Continue to build regional consensus and pressure, particularly from Afghanistan’s neighbours and the GCC to ensure that the IEA does not support, patronise, or shelter violent groups that are a direct threat to countries like Pakistan, China, Uzbekistan, Turkmenistan, and Iran. In this context, Saudi Arabia and the United Arab Emirates are of particular significance, as the IEA survival is increasingly tied to the Afghan Taliban’s legitimacy.

Military

1. Consider engaging with international partners (including both bilateral and multilateral partners) to explore deeper joint intelligence work, as well as options for joint over-the-horizon kinetic operations and strikes that target key terrorist leaders and networks – instead of relying on unilateral operations. Bilateral partners may include the United States, whilst multilateral partners may include a range of potential regional frameworks, including the SCO, GCC and others.
2. Forge better intelligence gathering and sharing with key partners, including Afghanistan’s neighbours and the US to better facilitate tracking, targeting, and elimination of key terror figures.

Disclaimer: The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of Tabadlab Private Limited.

Endnotes[1]https://www.thenews.com.pk/print/1014556-hina-rabbani-to-visit-afghanistan-on-29th

[2]https://profit.pakistantoday.com.pk/2021/03/24/pakistan-loses-spot-as-top-trade-partner-of-afghanistan/

[3]https://www.aljazeera.com/news/2022/6/3/pakistan-taliban-says-ceasefire-with-govt-in-islamabad-extended

[4] https://www.aljazeera.com/news/2022/12/2/assassination-attempt-on-pakistan-envoy-in-afghan-capital

[5] https://www.pakembassykabul.org/en/information/ambassador/

[6] https://mofa.gov.pk/press-release-546/

[7] https://carnegieendowment.org/2021/12/21/evolution-and-future-of-tehrik-e-taliban-pakistan-pub-86051

[8] https://www.reuters.com/world/asia-pacific/pakistans-new-army-chief-says-will-defend-motherland-during-visit-disputed-2022-12-03/

[9]https://www.longwarjournal.org/archives/2022/11/taliban-ends-ceasefire-with-pakistani-government-vows-revenge-attacks-across-the-country.php

[10] https://www.dawn.com/news/1660188

[11] https://www.dawn.com/news/1660188

[12] https://www.state.gov/wp-content/uploads/2020/02/02.29.20-US-Afghanistan-Joint-Declaration.pdf

[13]https://www.defense.gov/News/News-Stories/Article/Article/2573268/biden-announces-full-us-troop-withdrawal-from-afghanistan-by-sept-11/

[14]https://www.whitehouse.gov/briefing-room/speeches-remarks/2021/07/08/remarks-by-president-biden-on-the-drawdown-of-u-s-forces-in-afghanistan/

[15] https://www.cfr.org/backgrounder/taliban-afghanistan

[16] https://cisac.fsi.stanford.edu/mappingmilitants/profiles/tehrik-i-taliban-pakistan

[17]https://carnegieendowment.org/2021/12/21/evolution-and-future-of-tehrik-e-taliban-pakistan-pub-86051

[18] https://twitter.com/IftikharFirdous/status/1427543775178600477?s=20

[19]https://www.reuters.com/world/asia-pacific/pakistan-taliban-demand-prisoner-release-condition-talks-sources-2021-11-06/

[20] https://tribune.com.pk/story/2333199/dozens-of-ttp-members-freed-as-truce-holds

[21] https://thediplomat.com/2022/08/pakistans-peace-gamble-with-the-tehreek-e-taliban-pakistan/

[22] https://www.usip.org/publications/2022/01/after-talibans-takeover-pakistans-ttp-problem

[23] It is worth mentioning here that under the NAP-mandated military courts, 345 people were sentenced to death, and of the 8,000 or so prisoners on death row, another 56 were hanged. The latter also required the reversal of a moratorium that has been in effect since 2008, and is back in effect now, at least in spirit, if not in letter. The last sentencing was in 2019, and the last hanging was in Dec 2019.

[24] https://www.nytimes.com/2021/10/02/world/asia/pakistan-taliban-talks.html

[25]https://www.newsweekpakistan.com/military-ops-against-ttp-to-continue-till-menace-wiped-out-dg-ispr/

[26] https://dailytimes.com.pk/1033490/hina-rabbani-khar-in-afghanistan-on-day-long-visit/

[27] https://www.dawn.com/news/1724302

[28] https://dunyanews.tv/en/Pakistan/677949-Afghan-govt-condemns-attack-on-Pakistan-envoy;-assures-/’serious-investig

[29] https://arynews.tv/pakistan-army-soldier-martyred-cross-border-attack-ispr/

[30]https://www.aljazeera.com/news/2021/8/29/pakistani-soldiers-killed-in-cross-border-fire-from-afghanistan

[31] https://www.dawn.com/news/1665630/border-spat-with-taliban-resolved-official

[32]https://www.reuters.com/world/asia-pacific/five-pakistan-soldiers-killed-attack-afghanistan-military-says-2022-02-06/

[33]https://www.reuters.com/world/asia-pacific/taliban-pakistani-forces-clash-along-border-casualties-reported-2022-09-14/

[34] https://tribune.com.pk/story/2386288/chaman-border-closed-for-indefinite-period-following-clashes

[35] https://tribune.com.pk/story/2388664/new-coas-gen-asim-takes-reins

[36]https://www.aljazeera.com/news/2022/10/11/thousands-protest-rising-violence-in-pakistans-swat-valley

[37] https://tribune.com.pk/story/2330584/govt-releases-over-100-ttp-prisoners-as-goodwill-gesture

[38] The status of the enemy, under international law, is quite complicated. In one instance, this is non-international armed conflict; on the other TTP’s majority in Afghanistan implies it is international armed conflict.

[39] https://tolonews.com/afghanistan-176201

[40] https://www.dawn.com/news/759523/durand-line-a-settled-issue-says-pakistan

[41]https://www.france24.com/en/live-news/20220417-afghanistan-death-toll-in-pakistan-strikes-rises-to-at-least-47-officials

[42]https://www.voanews.com/a/taliban-condemn-pakistan-for-alleged-cross-border-attacks-in-afghanistan/6532351.html

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Insights from the UN EGDI 2022The need for responsive service delivery during Covid-19 catalysed digitisation globally. As the requirement for digital public service delivery became more obvious, governments around the world increasingly adopted digital technologies. The latest UN E-Government Development Index (EGDI) 2022 – a biennial measure of e-government across 193 countries – also reflects these trends.

Despite improvement, Pakistan continues to underperform on the EGDIThe average global EGDI score rose by 2% between 2020 and 2022. Two-thirds of the countries covered in the index now fall into the High or Very High EGDI groups.1

During this same period, Pakistan’s EGDI score rose by only 1.3%. In relative terms, Pakistan’s EGDI score is 31% lower than the global average. This ranks Pakistan at 150 out of 193 countries in the index, making it a Middle-EGDI performer with a meagre rank improvement of 3 positions. Worryingly, the EGDI score gap between Pakistan and other countries is inflating.

Looking at the region, Pakistan’s EGDI score is 35% lower than the Asian average, placing Pakistan as the fifth worst e-government regime in the region. An analysis of regional EGDI performance over the last two decades reflects the relative progress countries have made towards government digitisation. While Pakistan started off at a comparably strong position, the country’s overall EGDI rank has declined in this period. On the other hand, countries like Bhutan and Bangladesh have shown steep growth, leaving Pakistan behind.

Pakistan’s 13 rank fall in the last two decades – despite a 71% increase in absolute EGDI score – highlights the relatively slow pace of digital government transformation in the country.Understanding Pakistan’s wavering EGDI performanceA closer look at the last decade alone reveals an overall improvement in Pakistan’s EGDI rank and score. However, the country’s trajectory is characterised by a slow and fluctuating growth in ranking. The phases of Pakistan’s EGDI performance over the last decade are summarised below:

• 2012 – 2016: Decrease in rankings by 3 positions, demonstrating a consistently declining trend
• 2016 – 2018: Dramatic improvement of 11 positions in ranking, coinciding with the launch of the Digital Pakistan Policy, 2018
• 2018 – 2020: A 5 position drop in ranking, marking another dip in the country’s performance
• 2020 – 2022: A slight improvement of 3 positions, despite the covid-driven impetus to accelerate digitisation.

Out of the three components measured on the EGDI, Pakistan’s consistent low performance on TII (Telecommunication Infrastructure Index) and HCI (Human Capital Index) have resulted in a low overall EGDI score over the years. While TII and HCI show the quality of the enabling digital ecosystem, OSI (Online Service Index) measures the provision of public service delivery – the fundamental component of any digital government agenda.

Pakistan’s poor core internet connectivity is reflected in its low TII score – which was almost 50% below the regional average this year. While there are approximately 124 million mobile broadband subscribers in the country, according to the EGDI only 1.14% are active subscribers. This indicates limited access and shallow uptake of internet services.

Pakistan’s below average performance on the HCI suggests that citizens’ access to digital services is further compromised. The country’s 58% adult literacy rate indicates low levels of digital literacy, restricting citizens’ ability to meaningfully engage with digital technologies.

In contrast to the TII and HCI scores, Pakistan’s performance on the OSI has been significantly better, with scores higher than global and subregional averages providing a significant boost to Pakistan’s overall EGDI performance. Pakistan scores 2% and 6% higher than global and South – Asian average, respectively.

Unpacking Pakistan’s high OSI score reveals poor digital service deliveryInterestingly, Pakistan’s rise along the OSI is fairly recent. Until 2016, Pakistan’s OSI scores fell in the low-mid OSI range. However, in the 2018 edition of the EGDI, Pakistan’s absolute OSI score increased by 68%, promoting the country to the High OSI group. This sharp rise reflects a focus towards online government service delivery.

While there has been undeniable progress in digitisation of public services, the high OSI ranking is not accompanied by a corresponding sophistication in integrated digital service delivery. The disconnect between the ranking and user experience is better understood by unpacking Pakistan’s OSI scores.

The composite OSI measures countries against five aspects of digital service delivery: (i) Institutional Framework, (ii) Service Provision, (iii) Content Provision, (iv) E-Participation, (v) Technology. Service provision and e-participation indicators carry 80% of the total weightage.

Unsurprisingly, Pakistan performed very poorly across service provision and e-participation. However, a perfect score in content provision, and a high score on institutional framework development, skews the results to create a high OSI score. As such, the OSI ranking does not paint an accurate picture of Pakistan’s e-government ecosystem, failing to adequately capture the sophistication and maturity of digital initiatives.

Pakistan’s EGDI performance shows persistent systemic gaps in the e-government ecosystemDigital government maturity continues to be shallow, indicating gaps in a coherent and integrated digital government strategy. Some of the more pervasive issues include:

Prioritisation of content provision over service delivery: Online content provision is the lowest rung of e-government development, comprising a non-interactive web page which merely publishes relevant information. Conversely, online service provision is the digitised delivery of services, usually through an interactive, one-stop-shop portal.

Focusing on the former has restricted the growth of Pakistan’s digital government agenda, and limited the depth of digital service delivery in the country.

Global e-government leaders, as well as countries that have recently leapfrogged, show that growth in this space is predicated on the shift to a transformational model of e-government one that provides end-to-end digitisation across all stages of service delivery. Regional leaders in the Very-High category on average score 33% more on Service Provision than Pakistan.

Limited focus on citizen centricity: Pakistan’s current digital government landscape has relied on replication of existing service delivery processes reflecting internal government workflows. Inevitably, the focus of government digitisation has been procedural compliance rather than citizen need and ease. An outcome of this is the existing plethora of websites at the provincial and federal level for specific programmes and organisations. In contrast, almost three quarters of surveyed countries have single access points for all government services, such as “gov.uk” and “gov.rw” for the UK and Rwanda respectively, which are designed to optimise user journey for digital public services. Although there has been some provincial level progress with the introduction of the GoPunjab app and KP’s Super App, the scalability and efficiency of these apps remains to be tested.

Pakistan’s predominant focus on complaint and grievance redressal has led to a limited scope for citizen engagement through digital portals, as reflected in the country’s poor e-participation ranking (106). This leads to lower prioritisation of participatory approaches that can seek inputs for planning and implementation of key policies, programmes, and services through proactive digital engagement.

Fragmented and siloed governance: The increased legislative, policy and regulatory activity around the digital agenda in recent years is reflected in Pakistan’s high score (92%) on the institutional framework sub-indicator. However, implementation of these policies remains constrained due to institutional and governance considerations under a federal structure. Although federal and provincial governments continue to develop and grow their respective digital services portfolios, the absence of a coherent and organised national agenda and plan creates a noticeable difference in digital public service delivery across provinces.

Moreover, a lack of coordination and interoperability between and across different departments also leads to data silos, hindering a holistic, seamless experience for citizens. Real progress on the government digitisation front requires horizontal and vertical integration across federal and provincial departments.

Sustainable OSI growth: the Rwandan exampleRwanda, a low-income country with USD 720 GNI per capita, ranks 119 (out of 193) on the EGDI. The East-African country serves as a case study for countries with low TII and HCI, since it has progressed positively on OSI owing this progress specially to improved service delivery.

Rwanda’s OSI scores improved by 99% in the last decade. The improvement can be attributed to the country’s proactive implementation of core digital fundamentals vis-à-vis online services provision.

Rwanda’s major successes in this regard include:

• An increase in the number of online services being offered by public institutions. Currently, Rwanda offers 98 online services.
• Keeping user centricity as a driving force in defining the usability of these online services.
• The development of data-sharing mechanisms between departments to enhance inter-departmental collaboration. This has allowed the country to break silos resulting in cohesive policy decisions. You can download the PDF version here.

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The Problem: A Nationwide Shortage of PanadolOn October 21, 2022, in a regulatory filing to the Pakistan Stock Exchange (PSX), GlaxoSmithKline Consumer Healthcare (GSKCH) Pakistan Limited formally announced the suspension of manufacturing Panadol – a generic paracetamol drug for reducing pain and fever.[1]

The news came after months of reported shortages of the product in the market, and GSKCH’s persistent requests to the regulatory authorities to increase the selling price of the drug owing to the marked increase in costs of input materials. GSKCH has now restarted manufacturing Panadol, but this was not the first time that a pharmaceutical product was unavailable in the market due to price controls and other regulatory challenges. To understand the factors that led to the shortage, it is critical to understand the series of events that preceded it.

Events Leading Up to Suspension of Panadol ProductionAmid increasing prices and the depreciating value of the Pakistani Rupee (PKR), in January 2022 GSKCH requested – and received – an approval to increase the price of Panadol from the Drug Pricing Committee (DPC) of the Drug Regulatory Authority of Pakistan (DRAP). The DPC forwarded the recommendation to the federal cabinet, which, after a prolonged delay, rejected the recommendation without intimating any reasons to the company.[2]

On August 25, 2022, DRAP did grant GSKCH a routine Consumer Price Inflation (CPI) adjustment for 2022 – as the drug pricing policy allows pharmaceutical companies to increase the prices of their products according to inflation measured by CPI. However, this was not sufficient to counter the exorbitant increase in raw material costs.[3]

The Recent Panadol Saga

Earlier this year, the PTI government had agreed to increase drug prices. However, before an official decision could be made, then Prime Minister Imran Khan was ousted by a ‘vote of no confidence’.[4] Under pressure, the new coalition government “got cold feet”[5] and did not follow through on the previous government’s decision. GSKCH, which manufactures 450 million Panadol tablets a month,[6] reduced its production by one-third, starting the shortage in the market.[7]

Although Prime Minister Shehbaz Sharif did step in later (September 2022) to announce subsidies to producers of Paracetamol,[8] removing duties and taxes on Active Pharmaceutical Ingredients (APIs) required to produce the drug.[9] However, it could not materialise due to limited fiscal space and no rules to implement the subsidy,[10] while pressures on pharmaceutical companies continued to mount.

As described above, since DRAP recommended a price increase of PKR 1 for all paracetamol tablets[11] and the federal cabinet subsequently rejected the summary, the situation evolved in an unprecedented fashion. On September 12, 2022, the Federal Minister for National Health Services, Regulations and Coordination (NHSR&C) Abdul Qadir Patel commented that the medicine remains in abundance and the government will not increase prices, while alleging pharmaceutical companies of “blackmail” and creating an artificial shortage.[12]

On September 16, 2022, Sindh’s health authorities raided the warehouse of a distribution company named Connect – a subsidiary of GSKCH. They found 48 million Panadol tablets at the warehouse and accused GSKCH of hoarding the paracetamol medicine.[13] The confiscated inventory was estimated to be worth PKR 250 million.[14]

GSKCH responded by clarifying that this stock was scheduled to be ‘released and distributed in the country in the normal course of business.’[15] As per the company’s Supply Chain Policy, it is a Standard Operating Procedure (SOP) to maintain a 30-day safety stock at their warehouse.[16]

Pakistan’s pharmaceutical industry does not produce most of the active ingredients required to manufacture drugs, making the industry dependent on the import of raw materials to continue production.[17] Furthermore, these imported ingredients have themselves been difficult to procure in the international market due to global supply shortages and disruptions, as well as the depreciation of the PKR.[18] In case of producing Panadol tablets, GSKCH purchases a “major chunk” of paracetamol from Citi Pharma Limited, whereas the raw material used by Citi Pharma to produce paracetamol is imported, making it subject to the challenges described.[19]

The matter was finally resolved when Federal Finance Minister Senator Mohammad Ishaq Dar met with the heads of Pakistan’s major pharmaceutical companies on October 26, 2022.[20] GSKCH has restarted production of Panadol as all parties negotiated to a middle ground by increasing the price of a 500mg tablet of paracetamol to PKR 2.35, an increase which is 50% less than the initial proposal.[21]

The Wider Repercussions: Another Dent to Investor ConfidenceThe unfair treatment GSKCH has faced at the hands of the public authorities during the Panadol shortage has further hurt foreign investor confidence, as many multinationals have already pulled out of the country in the recent past due to government’s ad hoc policies and regulations[22] – over the last 18 years, 26 international pharmaceutical companies have stopped operating in Pakistan.[23]

Recently – in November 2022 – Eli Lilly Pakistan (Pvt) Limited also announced that it is ceasing operations in Pakistan, while sources from Pakistan Pharmaceutical Manufacturers Association (PPMA) commented that three more multinational pharmaceutical companies are planning to leave Pakistan in 2023.[24]

The Panadol fiasco has also damaged the sentiments of the local business community, as they perceive these events as yet another series of avoidable losses for the industry,[25] incurred only due to a fractured regulatory system.

Populist Policies at Play: Decisions to increase or decrease pharmaceutical product prices are always shaped by populist political narratives rather than sound industry expertise and market requirements. Federal Minister Abdul Qadir Patel’s remarks of being ‘blackmailed’ and asking media outlets to investigate or expose pharmaceutical companies can also be considered an example of this. Similarly, it is interesting to note that there have been multiple recent instances where the government/federal cabinet has rejected the price increase recommended by DRAP.[26] [27] [28]

The Context: Pharmaceutical Sector Regulation and Price ControlsThe pharmaceutical industry of Pakistan is subject to substantial government control. From licensing to manufacturing, importing and/or distributing to advertising, pricing, and public procurement almost all aspects of the industry are regulated. While many of these regulatory features may be debatable, this paper will focus on one of the most contested topics, pricing.

Over the course of time, pricing regulations have been, evolved, dictated, and governed by three main legal actions:

1. Drugs Act 1976
2. DRAP Act 2012
3. Drug Pricing Policy 2018

Drugs Act 1976The Drugs Act of 1976 was introduced during Zulfiqar Ali Bhutto’s regime in a bid to prevent the consumption of ‘dangerous or substandard’ medicines and keep medicines affordable for the public.[29] The 1976 Act gives the Federal Government power to ‘fix [the] maximum prices of drugs’ at which they are to be sold, and ‘specify a certain percentage of the profits of manufacturers of drugs’ for research on drugs.[30] It still remains the primary legislation that governs the pharmaceutical industry.

While this was a well-intended initiative, the Drugs Act of 1976 did not establish any formula on how the government will determine prices. Consequently, during the policy period, the Maximum Retail Price (MRP) of drugs were fixed on an ad hoc basis.[31] Under the same policy, Pakistan’s pharmaceutical industry also saw ‘a virtual price freeze on medicines’ from 2001 to 2013[32] – a period where private companies struggled to continue business operations as margins diminished due to rising costs.

DRAP Act 2012In the backdrop of 2010’s 18th Amendment (which devolved the management of public health to the provinces), a virtual price freeze, and mounting pressures on public stakeholders to efficiently regulate the industry, the Drug Regulatory Authority of Pakistan (DRAP) Act 2012 was legislated. The DRAP Act 2012 allowed the establishment of DRAP, an autonomous arm of the Ministry of National Health Services Coordination and Regulation (MNHSCR). DRAP replaced the Drug Control Organisation (DCO) which worked prior to devolution.[33] After devolution, and the introduction of the 2012 Act, provinces controlled the distribution and sales of drugs, but the federal government managed all other aspects (licensing, pricing, import, export, manufacturing, etc.).[34]

DRAP carries out its administrative role through three boards[35]:

1. Policy Board – responsible for overall management and executive decisions of DRAP
2. Licensing Board – grants licenses for the manufacture of therapeutic goods
3. Registration Board – regulates the grant of registration to therapeutic goods

The regulatory body provides strategic support to the provincial health departments and works in tandem with the respective Provincial Quality Control Boards.[36]

Drug Pricing Committee (DPC)

The rollout of DRAP Act 2012 provided the impetus to formally constitute a Drug Pricing Committee (DPC) through a Statutory Regulatory Order (SRO) on August 6, 2013.[37] The DPC was vested with the responsibility to formulate the pricing of drugs throughout the country.

Later, court orders clarified that DPC would only recommend prices, and the final decision regarding price changes will be taken by the Federal Cabinet.[38]

The members of the committee comprise of[39]:

1. Director Costing and Pricing, DRAP
2. Secretaries, Department of Health from each province or their nominees not below the rank of an officer of BPS-19
3. Chief Cost Accounts Officer or Cost Accountant, Ministry of Finance, Government of Pakistan
4. Deputy Director General (Pricing)/Deputy Drugs Controller (Pricing), DRAP
5. Representative of Pakistan Medical Association
6. Representative of Consumer Rights Commission of Pakistan
7. Representative of Pharma Bureau (Overseas Investors Chamber of Commerce and Industry)
8. Representative of Pakistan Pharmaceutical Manufacturers Association

The composition of the DPC was formulated with a view to ensure a wide spectrum of stakeholder representation – from public entities to consumers and commercial businesses.

Drug Pricing Policy 2018The Drug Pricing Policy – initially formulated in 2015 – was later revised and updated in 2018. Notably, the Drug Pricing Policy of 2018 divides medicines into two categories: drugs and biologicals on the National Essential Medicines List, and all other drugs. The National Essential Medicines List is a list of essential drugs and biologicals published by DRAP, updated or revised after three years in accordance with the World Health Organization (WHO) list of essential medicines.[40]

The policy primarily follows the External Reference Pricing (EPR) system. DRAP establishes Maximum Retail Price (MRP) for all kinds of drugs. Broadly, if a drug is introduced in Pakistan that already exists in India and Bangladesh, then MRP is set by calculating the average price in the two countries. However, in cases where the drugs are not marketed in these two countries, the MRP is calculated by taking the average retail price of a basket of countries which includes Indonesia, Philippines, Lebanon, Sri Lanka, and Malaysia. The MRP of generics are set at 30% less than the MRP of the Originator Brand (a branded drug containing a new chemical entity developed through research and development).[41]

The policy also allows manufacturers and importers to increase drug prices within a particular set of caveats. In the case of essential drugs or biologicals – excluding lower priced ones – firms are allowed to raise prices by up to 70% of the increase in the Consumer Price Index (CPI), provided the rise does not exceed 7% of the original amount. Whereas, in the case of all other drugs, biologicals, and lower priced drugs, firms are allowed to raise prices equivalent to the increase in the CPI, so long as that is not greater than 10% of the drug’s original price. However, these increases can only be implemented after authorisation by DRAP.[42]

In the Case of Panadol Shortage:

Paracetamol manufacturers had demanded a price increase of 42.78% (from PKR 1.87 to PKR 2.67) – much higher than the thresholds of 7% and 10% described above. In the end, the government decided to increase the price by 25.67% to PKR 2.35.[43]

The policy also has a provision of ‘Hardship Cases’ where manufacturers and importers under extraordinary circumstances can request DRAP to re-evaluate prices if they are unable to recover costs and profit margins through existing MRPs, with escalating production costs and tightening exchange rates. Companies can apply for this provision once in three years after making an MRP review fee payment.[44]

In the Case of GlaxoSmithKline Pakistan Limited:

GlaxoSmithKline (GSK) Pakistan Limited has had a rocky relationship with regulators when it comes to applying and availing the ‘hardship case’ provision. The rollout of the first Drug Pricing Policy 2015 mandated that all hardship cases will be decided within nine months. However, GSK Pakistan’s prior applications to avail the provision did not receive any decision in the stipulated time. A prolonged delay and multiple court rulings (both by Sindh High Court and Supreme Court) later, GSK Pakistan was asked to resubmit the applications to DRAP – a tedious process, with looming uncertainties of adverse financial impact.[45]

From Skewed Incentives to Force Majeure: Stakes and IncentivesTo understand the nature of this regulatory challenge, it is crucial to first identify the stakes and incentives for the three key actors in this space.

Pakistani ConsumersThe two critical considerations for consumers of pharmaceutical products are affordability and accessibility. In 2019, the out-of-pocket (OOP) expenditure in Pakistan as a percentage of total health expenditure was 53.81%.[46] Moreover, the 2019-20 National Health Accounts survey showed that 50.63% of the total OOP Expenditure on health by private households was on “medicines/vaccines”.[47] Therefore, in the current scenario, drug prices are a major concern for the ordinary consumer, explaining the persistent public opposition to exorbitant hikes in drug prices.

Another increasingly significant demand of consumers is accessibility to all kinds of pharmaceutical products. Even after the introduction of DRAP, shortage of medicines remains a common phenomenon. The reasons for scarcity in supply range from contested prices to inefficient procurement processes at the provincial health department levels. The growing frustration of the public is justified: over the past decade, common medicines like Panadol, Buscopan, Ritalin, and Sovaldi have all seen shortages in the Pakistani market and have been sold in the black market for higher prices.[48]

Pharmaceutical Manufacturers, Importers, and Distributors (Local and Multinationals)The private sector sees the current regulatory structure as too tight, with limited room for innovation and expansion. While private entities wish to increase their margins and maximise their profits, they are also a driver of research and innovation. Multi-National Corporations (MNCs) provide healthy competition to local players and influence them to continue evolving their products and processes. The private sector requires a regulatory structure that will enhance their current supply chains and product offerings rather than restricting or limiting them. While manufacturers, importers and distributors want fewer price controls so that they may increase prices as per market conditions, they are willing to be taxed. These taxes could be used to create funds for research and development, or to provide subsidies to minimise OOP expenditure for the poor.

The Pakistani GovernmentGovernment entities – both federal and provincial – and public authorities such as DRAP are all essentially striving to create an equilibrium where

• pharmaceutical products are affordable and accessible for the public;
• the pharmaceutical industry is regulated such that safe products are produced, ethically marketed, and efficiently distributed;
• a business environment is developed which is conducive to the growth of local players within the sector, avoids monopolies and rent seeking behaviour, attracts Foreign Direct Investment (FDI), promotes trade (mostly exports), and helps the industry mature overall; and,
• a fair taxation regime can build funds for research and development is instituted.

Balancing these competing priorities is a tremendous challenge. Without reprioritisation, future goal setting for the industry, and redefining clear roadmaps for entities such as DRAP, this constant push and pull will continue.

While this paper primarily discusses the recent Panadol shortage, drug shortages are not new or limited to any specific medicine. The next section will analyse the larger challenges of the regulatory structure governing the pharmaceutical industry in Pakistan and seek to explain how the current environment has evolved.

The broader challengesThe multiple regulatory issues of the pharmaceutical industry can be classified into four broad categories of challenges as described below.

Inconsistencies in policy directivesTwo overlapping but separate sources of inconsistency in policies inhibit private sector confidence and reliability of public stakeholders in the industry:

1. Ad hoc-ism due to changing government priorities and lack of mid- to long-term planning – This was evident when, in 2020, holders of valid Drug Manufacturing Licenses (DML) were allowed to manufacture hand sanitisers for three months, but later the directive was reversed by the Cabinet without any formal reason. Similarly, while SROs in 2010 and 2013 discouraged imports, an SRO in 2016 allowed a five-year exemption for the import of drugs meant for donations without any fool proof mechanism to check the abuse of this exemption by individuals or companies.[49]
2. Decisions colluded by populism – as mentioned in section 1.2. there have been multiple occasions where recommendations by DRAP’s DPC are rejected by the Federal Cabinet, or the Federal Cabinet has reversed its decision to increase prices due to public outcry. These reversals are charged by political motivations to win over the public and not grounded in the technical expertise required to keep the market afloat. Another example of this occurred in 2013 when the Prime Minister reversed the decision to end the price freeze policy in 2013 within two days of it being taken.[50]

Reactive instead of proactiveOn multiple occasions, DRAP’s processes and systems have proven to be slow, and the decision making has been reactive instead of proactive. As can be concluded from this year’s Panadol shortage, DRAP did not have a mechanism to proactively foresee the rising raw material costs for manufacturers and pre-empt the repercussions of the fractured global supply chain caused by the pandemic.

Similarly, during the 2022 floods, multiple drug and medicines shortages were reported across the country.[51] [52] The climate induced calamity created a shortage in both public and private facilities, as the provincial health departments struggled to procure more medicines.[53] [54] The regulator was not able to intervene and ensure a strong – or indeed any – response to mitigate hoarding.

Covid-19 exhibited that DRAP was not prepared to deal with a pandemic. The vaccine procurement process was mostly managed by the Federal Government with limited visibility by DRAP. The regulator had not conducted any research on vaccines and there was no technical or operational expertise to start developing vaccines locally, again leaving the country susceptible to import markets.[55]

Rent seekingThe untimely or delayed increase in prices of drugs also encourages rent seeking behaviour in some ways. When prices are not increased and manufacturing of a certain drug halts, the shortage may benefit some stakeholders of the ecosystem as described below:[56]

• The shortage may be balanced through imports, which will favour importers of similar drugs.
• If the drugs that become too expensive to produce are first-generation drugs, then the same company can start manufacturing and introduce second- or third-generation drugs over the medium-term in the market.
• In instances of shortage, many drugs are hoarded, smuggled, and sold on the black market, thereby creating markets of exploitation.

Active Pharmaceutical Ingredients (APIs) not being produced locallyThe amount of Active Pharmaceutical Ingredients (APIs) produced in Pakistan is negligible as 95% of APIs are imported, with India and China being the primary sources.[57] Relying on imports for the raw material for most pharmaceutical products means that Pakistan’s pharmaceutical sector and stakeholders are always susceptible to the impacts of a depreciating local currency, the risk of supply chain breaks, and other externalities.

RecommendationsThe pharmaceutical industry must be regulated to keep private stakeholders aligned with the objectives of the government and ensure greater public good by keeping essential drugs affordable and accessible. However, regulatory structure should encourage research, innovation and industry development – especially from local businesses – to make the sector competent, competitive, and future-ready.

DRAP was created to catalyse industry growth, while rationalising commercial incentives and curbing rent-seeking behaviour. The following recommendations may assist in making the regulatory regime and pricing mechanisms more robust and effective.

1. Explore and Develop Holistic Pricing Models:
2. Shift away from the one pricing model (External Reference Pricing) and introduce a blend of pricing models tailored to Pakistan’s health system and dynamic industry scenarios, that can adjust to the need of the hour.
   • WHO describes various pricing models that can be explored by Pakistan, and implemented according to the country’s health system[58] – some suitable models are Internal Reference Pricing, External Reference Pricing (already implemented), Value Based Pricing, Mark-up Regulations.
3. Benchmark against countries with similar socioeconomic and industry maturity as Pakistan – not countries like Malaysia who have ‘a free market economy with no control over drug prices.’[59]
4. Improve Price Revision Processes:
5. Devolve the price change (increase or decrease) responsibility to the DPC or provincial health departments to mitigate political bias and populist decision making.
6. Revise and enhance the drug pricing policy to set predefined formulae that automate drug pricing mechanisms for most essential drugs, only requiring final approval from the DPC.
7. Stimulate Research and Innovation:
8. Effectively utilise the already established Central Research Fund (CRF), a deposit pooled in through contributions amounting to 1% of the gross profits of licensed companies.
   • Realign the CRF to effectively utilise the money towards funding research and innovation in the health systems and pharmaceutical industry.

Establish a separate fund – with contributions from private companies – to subsidise OOP healthcare payments for the lowest quintile income groups, instead of tightening price controls.

1. Endnotes[1] Alam, K. (2022). GSK suspends manufacturing of Panadol, says it’s losing money. Dawn. https://www.dawn.com/news/1716270.

[2] Alam, K. (2022).

[3] Alam, K. (2022).

[4] BBC News. (2022). Imran Khan ousted as Pakistan’s PM after vote. BBC. https://www.bbc.com/news/world-asia-61055210.

[5] Ali khizar [@AliKhizar]. (2022, October 22-a). Previous PTI govt was about to increase prices; but VONC came. The new govt got cold feet. Refused to do the necessary. GSK reduced the production to 1/3rd. The product got short in the market 2/. Twitter. https://twitter.com/AliKhizar/status/1583688499860905984.

[6] Shahid, A. (2022). The mechanics behind the panadol shortage. Profit. https://profit.pakistantoday.com.pk/2022/09/18/the-mechanics-behind-the-panadol-shortage/.

[7] Ali khizar [@AliKhizar]. (2022, October 22-a).

[8] Daily Pakistan. (2022). Pakistan to subsidise Paracetamol, Panadol as price hike causes shortage amid huge demand. Daily Pakistan. https://en.dailypakistan.com.pk/22-Sep-2022/pakistan-to-subsidise-paracetamol-panadol-as-price-hike-causes-shortage-amid-huge-demand.

[9] Bhutta, Z. (2022). Govt mulls making paracetamol duty free. The Express Tribune. https://tribune.com.pk/story/2378824/govt-mulls-making-paracetamol-duty-free.

[10] Ali khizar [@AliKhizar]. (2022, October 22-b). Then PM instead of increasing prices announced to give subsidy with no fiscal space n no rules to dole out subsidy. It was never supposed to happen. Seeing all that GSK declared force majeure to produce Panadol range. 4/. Twitter. https://twitter.com/AliKhizar/status/1583688508639653888.

[11] Shahid, A. (2022).

[12] Junaidi, I. (2022-a). Ministry to inspect pharma units ‘hit by shortages’. Dawn. https://www.dawn.com/news/1709859.

[13] Ayub, I. (2022). Over 48m Panadol tablets seized in Karachi raid. Dawn. https://www.dawn.com/news/1710347.

[14] Ali, I. (2022). 48m ‘hoarded’ Panadol tablets confiscated from warehouse in Karachi’s Hawkesbay: Sindh govt. Dawn. https://www.dawn.com/news/1710249.

[15] Shahid, A. (2022).

[16] Shahid, A. (2022).

[17] Dawn. (2022-a). Panadol shortage. Dawn. https://www.dawn.com/news/1711680.

[18] Dawn. (2022-a).

[19] Alam, K. (2022).

[20] Ministry of Finance [@FinMinistryPak]. (2022, October 26). Federal Finance Minister Senator Mohammad Ishaq Dar in a meeting with heads of main pharmaceutical companies discussed the retail price of paracetamol products. The pharma industry agreed upon the reduced prices of paracetamol 500mg tablet at Rs. 2.35,..(1/2)… Twitter. https://twitter.com/FinMinistryPak/status/1585224572571250688.

[21] Business Recorder. (2022). Pharma firms to resume production of paracetamol after meeting with Dar: Ministry of Finance. Business Recorder. https://www.brecorder.com/news/40205268.

[22] Ali khizar [@AliKhizar]. (2022, October 22-c). Outcome – 1. Shortage of most selling product in days of viral spread. Masses to suffer 2. Investors sentiments to dampen as a foreign entity is harrased by one govt n refused for its right by the other. 5/5. Twitter. https://twitter.com/AliKhizar/status/1583688512712232966.

[23] Hussain, B. (2022). Eli Lilly ceases operations in Pakistan. Business Recorder. https://www.brecorder.com/news/40208321.

[24] Bhatti, M.W. (2022). Are pharma MNCs leaving Pakistan? The News. https://www.thenews.com.pk/print/1009046-are-pharma-mncs-leaving-pakistan.

[25] The Express Tribune. (2022-a). Panadol shortages cause anxiety in businesspeople. The Express Tribune. https://tribune.com.pk/story/2383315/panadol-shortages-cause-anxiety-in-businesspeople.

[26] Junaidi, I. (2022-b). Proposal to raise drug prices rejected. Dawn. https://www.dawn.com/news/1705331.

[27] Mehmood, K. (2022). Cabinet rejects increase in medicine prices. The Express Tribune. https://tribune.com.pk/story/2376471/cabinet-rejects-increase-in-medicine-prices.

[28] Khan, U. (2022). PM Shehbaz turns down summary to increase medicine prices. Samaa. https://www.samaaenglish.tv/news/40016924.

[29] Dawani, K. & Sayeed, A. (2020). Anti-corruption in Pakistan’s pharmaceutical sector: A political settlement analysis. Working Paper 25. Anti-Corruption Evidence (ACE) SOAS Consortium. https://ace.soas.ac.uk/wp-content/uploads/2022/04/ACE-WorkingPaper025-PakistanPharma-200701.pdf.

[30] Government of Pakistan. (1976). The Drugs Act 1976. https://www.dra.gov.pk/wp-content/uploads/2022/10/Drugs-Act-1976.pdf.

[31] Dawani, K. & Sayeed, A. (2020).

[32] Dawani, K. (2020). Why amending Pakistan’s drug pricing policy is a mistake. Anti-Corruption Evidence (ACE) SOAS Consortium. https://ace.soas.ac.uk/why-amending-pakistans-drug-pricing-policy-is-a-mistake/.

[33] Mehmood, S. (2022-a). Regulating the Pharmaceutical Industry: An Analysis of the Drug Regulatory Authority of Pakistan (DRAP). Chapter 2. Book 48 Evaluations Of Regulatory Authorities Government Packages And Policies. PIDE. https://pide.org.pk/wp-content/uploads/book-48-chapter-2-regulating-the-pharmaceutical-industry-an-analysis-of-the-drug-regulatory-authority-of-pakistan.pdf.

[34] Mehmood, S. (2022-a).

[35] Government of Pakistan. (2022). The Drug Regulatory Authority of Pakistan (DRAP) Act 2012. https://www.dra.gov.pk/wp-content/uploads/2022/10/DRAP-2012-_As-Amended-till-Feb-2022.pdf.

[36] Dawani, K. & Sayeed, A. (2019). Pakistan’s pharmaceutical sector: issues of pricing, procurement and the quality of medicines. Working Paper 12. Anti-Corruption Evidence (ACE) SOAS Consortium. https://ace.soas.ac.uk/wp-content/uploads/2022/05/ACE-WorkingPaper012-PakistanPharmaSector-190801.pdf.

[37] Drug Regulatory Authority of Pakistan. (2013). Statutory Regulatory Order (SRO). National Health Services, Regulations and Coordination Division. Government of Pakistan. https://www.dra.gov.pk/wp-content/uploads/2022/01/SRO-707-2013.pdf.

[38] Dawani, K. & Sayeed, A. (2019).

[39] Drug Regulatory Authority of Pakistan. (2013).

[40] Ministry of National Health Services, Regulations and Coordination. (2018). Drug Pricing Policy 2018. Government of Pakistan. https://www.dra.gov.pk/wp-content/uploads/2022/10/Drug-Pricing-Policy-2018-_As-amdended-till-August-2021.pdf.

[41] Ministry of National Health Services, Regulations and Coordination. (2018).

[42] Ministry of National Health Services, Regulations and Coordination. (2018).

[43] Dawn. (2022-b). Production resumes after 25pc rise in paracetamol rates. Dawn. https://www.dawn.com/news/1717119/production-resumes-after-25pc-rise-in-paracetamol-rates.

[44] Ministry of National Health Services, Regulations and Coordination. (2018).

[45] GlaxoSmithKline Pakistan Limited. (2018). Third Quarter Report 2018. https://pk.gsk.com/media/6175/gsk-q3-2018-report.pdf.

[46] World Health Organization. (2022). Global Health Expenditure Database. WHO. https://apps.who.int/nha/database/country_profile/Index/en.

[47] Pakistan Bureau of Statistics. (2022). National Health Accounts (NHA) Pakistan 2019-20. Ministry of Planning Development & Special Initiatives. Government of Pakistan. https://www.pbs.gov.pk/sites/default/files/national_accounts/national_health_accounts/NHA-Pakistan_2019-20.pdf.

[48] Mehmood, S. (2022-b). Ameliorating Drug Shortages in Pakistan. Policy Viewpoint. No. 37. PIDE. https://pide.org.pk/wp-content/uploads/pv-37-ameliorating-drug-shortages-in-pakistan.pdf.

[49] Mehmood, S. (2022-a).

[50] Dawani, K. (2020).

[51] Hussain, B. (2022). Drug shortage hits Karachi as demand exceeds supply. Business Recorder. https://www.brecorder.com/news/40196392.

[52] The Express Tribune. (2022-b). Medical supplies shortage. The Express Tribune. https://tribune.com.pk/story/2374958/medical-supplies-shortage.

[53] The Express Tribune. (2022-b).

[54] Abbas, D. (2022). Common medicines disappear from market. The Express Tribune. https://tribune.com.pk/story/2375858/common-medicines-disappear-from-market.

[55] Mehmood, S. (2022-a).

[56] Dawani, K. & Sayeed, A. (2019).

[57] Mehmood, S. (2022-a).

[58] World Health Organization. (2020).WHO guideline on country pharmaceutical pricing policies, second edition. Geneva: WHO. https://www.who.int/publications/i/item/9789240011878.

| [59] Babar, ZUD. (2022). Forming a medicines pricing policy for low and middle-income countries (LMICs): the case for Pakistan. Journal of Pharmaceutical Policy and Practice 15, 9. https://doi.org/10.1186/s40545-022-00413-3. |

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