Mapping the Gap: What a Review of 196 Pakistani Laws Against the International Health Regulations Found

When the external evaluators of the World Health Organization finished their mission to Pakistan on 24th May 2023, they scored the country two out of five on legal instruments under the International Health Regulations (2005), and they recorded the reason: Pakistan had conducted a legal mapping of the relevant instruments, but “formal assessments have not been conducted”. The first priority action they set against that score was a “scoping review for prioritization of public health laws related to IHR (2005), for further legal analysis to update IHR-related legislation”. Between March and November 2024 the legal workstream of the “Evidence for Health” programme of the United Kingdom’s Foreign, Commonwealth and Development Office carried out that work for the Ministry of National Health Services, Regulations and Coordination, in three stages: a legal mapping of 196 laws delivered on 28th April 2024, a scoping review delivered in May 2024, and an in-depth analysis of 26 laws whose final report is dated 18th November 2024.

I led that workstream as Team Lead and principal author, engaged as National Senior Legal Expert by Palladium Pakistan (Pvt) Limited, the programme’s implementing contractor, with a public health specialist and research associates beside me. What follows is what the three reports found, set out with Palladium’s written consent. None of it has been published before.

Why a score of two matters

The Joint External Evaluation grades each capacity on five levels. Level 2 on legal instruments means that the laws have been mapped. Level 3 requires a legal analysis, being mapping and assessment together, with the gaps identified and reviewed and the necessary instruments developed or revised. Pakistan’s overall score at the 2023 evaluation was 43 per cent, 121 of 280, against 48 per cent at its first evaluation in 2016, when it was the first State in the Eastern Mediterranean Region to undergo one.

Since the milestone for Level 3 is a completed legal analysis, therefore the three reports of 2024 were built to be that analysis, statute by statute, so that the next evaluation finds the assessment done. What the reports cannot supply is the last limb of the milestone, the revision of the instruments themselves, which belongs to Parliament and the Provincial Assemblies.

Stage one: 196 laws, and only 140 in field

The mapping examined 196 health laws promulgated from the pre-partition era to 2024. Many had never been adapted after 1947. Many others had been repealed or replaced, or had been made as Ordinances and lapsed after four months under Article 89 of the Constitution of the Islamic Republic of Pakistan, 1973; the National Disaster Management Ordinances of 2006, 2007 and 2009 are examples, as is the National Institute of Health Ordinance, 1980. Only 140 of the 196 were found to be in field and relevant, directly or indirectly, to the core capacities the Regulations require.

Each law was given an IHR code, a note of its jurisdiction after the Eighteenth Amendment, and a rating of high, medium or low relevance, and the whole was sorted into four clusters: preventive, curative, rehabilitative and miscellaneous. The cluster headed “Enforcement of IHR” is the one worth reading twice, because it collects statutes that no health official thinks of as health law: the Foreigners Act, 1946, the Ports Act, 1908, the Pakistan Civil Aviation Act, 2023, the Customs Act, 1969 (Act IV of 1969), the Federal Investigation Agency Act, 1974, the Prisons Act, 1894 and the Police Order, 2002. The Regulations are enforced at the border and in custody by officers who answer to other Ministries, hence a review confined to the health statutes would have missed the place where the obligations actually bite.

Stage two: 197 entries, 69 set aside, 128 scoped

The scoping review worked from the Ministry’s own list, which ran to 197 entries. It set aside 69 of them: 9 duplicates, 6 Hudood laws whose review carries religious and political difficulty, 4 laws never adopted, 1 draft Bill that was not law, 38 laws repealed or lapsed, and 11 statutory orders needing no review. The remaining 128 were described one by one, and the review proposed that the in-depth analysis proceed in phases by category: 26 health-specific public health laws, federal and provincial; 16 laws touching public confidence, such as social security, transplantation, tobacco and blood safety; 20 laws on the agricultural economy and food; and 62 on transnational security and the social determinants of health.

The arithmetic answers the first question every reform programme asks, which is where to begin. More than a third of the list on which the State was measuring itself was not law capable of review, and of what remained only 26 laws were public health laws in the strict sense.

Stage three: 26 laws, read section by section

The in-depth analysis took the first category through national and provincial consultations with health, law enforcement and disaster management officials, and examined each statute for its jurisdiction, its alignment with the Regulations, its gaps and the amendments it needs.

At the federal level, the National Institute of Health (Reorganisation) Act, 2021, promulgated on 10th August 2021, defines none of the terms an emergency turns on: “Public Health Emergency”, “Quarantine”, “Isolation”, “First Responder” and “Communicable Disease” are all absent. It confers no power to impose restrictions or to require screening, no power to suspend the operation of a port or airport where border capacity fails, and no power for police and immigration officers to hold a suspected infectious person for screening. No rules have ever been made under Section 29, and the analysis drew the consequence plainly: plans and strategies made under Sections 8 and 12 without statutory rules have no binding force, and officials are not legally bound to follow them. The Epidemic Diseases Act, 1897 gives its Section 2 powers to the Provinces in vague terms and says nothing of surveillance, reporting or preparedness. The Public Health (Emergency Provisions) Ordinance, 1944 leaves its own operative terms undefined and was recommended for repeal as redundant after devolution. The Vaccination Act, 1880 is still in field.

In Khyber Pakhtunkhwa, the Public Health (Surveillance and Response) Act, 2017 is the one provincial statute written expressly to carry the Regulations into provincial law, with a Public Health Committee, a Provincial Disease Surveillance Centre and a District Disease Surveillance Centre in each district. The analysis found it sound in design and weak in operation. “Health emergency”, “surveillance”, “notifiable disease” and “unusual public health event” are used throughout and defined nowhere. Section 10 allows reports to be shared “on immediate or weekly basis”, whereas the Regulations assume continuous surveillance. No rules have been made under it. Its surveillance mandate overlaps with that of the Khyber Pakhtunkhwa Epidemic Control and Emergency Relief Act, 2020, and the provincial officials consulted said that surveillance data held by federal entities and by hospitals under the armed forces was, in practice, very hard to obtain.

The recommendations for that Act were specific: define the terms; bring in “pandemic emergency” after the 2024 amendments to the Regulations; give one authority alone the power to declare an emergency, rather than leave it to overlap with the Provincial Disaster Management Authority; make the refusal to share surveillance data an offence binding federal entities as well as provincial ones; move from passive reporting by health establishments to active surveillance in the community; and replace paper reporting with a digital system working in real time. Those recommendations were made in November 2024, and they are the agenda for any revision of the 2017 Act now in hand.

Across all 26 laws one finding recurs. During COVID-19 lockdowns were imposed without a statutory foundation and people were confined without a quarantine law in field, although Article 89 was available to legislate by Ordinance and was not used. On 8th June 2020, in Suo Motu Case No. 1 of 2020, the Honourable Supreme Court of Pakistan asked whether any law had been made, and the Attorney General for Pakistan answered that some Provinces had legislated but that no law had been made at the national level. That remains the position today.

What the reports recommended

Two new statutes, urgently: a national enactment governing the emergency that infectious disease creates, and a Public Health Law for Islamabad covering communicable and non-communicable disease, solid waste, gatherings, maternal, newborn and child health and food safety on a One Health basis. Beyond those, the reports asked for a single platform in law at which public health, law enforcement, local health departments and the political leadership take decisions together in a national crisis; a statutory definition of “Public Health Emergency”; a declaration of emergency by the Prime Minister that carries sick pay, unemployment benefit and death benefits for “First Responder” families; and a data protection law fixing what citizens’ data may be shared, with whom and through which channel.

What has changed since November 2024

The obligation has grown. The amendments to the Regulations adopted in 2024 entered into force on 19th September 2025, and amended Article 4 requires each State Party to designate or establish a National IHR Authority to coordinate implementation across government. No Pakistani statute yet designates one, and the 2023 evaluation, published by the Organization in 2025, still records the legal capacity at the level of a map. The work of assessment that the evaluators asked for has been done; what is urgently required now is the legislation it points to, federal and provincial, written so that the two talk to each other.