Pakistan faces an unrecognized health challenge that may undermine progress in public health. While the acute phase of COVID-19 has subsided, a substantial burden of post-acute sequelae of SARS-CoV-2 infection—commonly known as Long COVID—likely persists among a significant portion of the population. The contrast between health systems actively addressing Long COVID and those that remain largely unaware of its magnitude underscores the need for a coordinated national response.
This policy analysis synthesizes global evidence on Long COVID prevalence and manifestations with emerging Pakistan-specific research to characterize the scale of this under-documented burden. The article combines evidence synthesis drawing on global meta-analyses and Pakistan-specific studies, health system assessment applying the WHO building blocks framework, and policy framework development proposing contextually adapted recommendations. We acknowledge that policy decisions cannot await perfect evidence in evolving public health situations; this analysis aims to bridge emerging scientific evidence and actionable health policy.
The insights extend beyond Pakistan to inform Long COVID responses across low- and middle-income countries facing similar healthcare infrastructure challenges.
METHODS
Search Strategy and Source Identification
We conducted searches in PubMed, Google Scholar, and institutional repositories (Aga Khan University, Pakistan Institute of Medical Sciences) between October and November 2025 using terms including “Long COVID,” “post-acute sequelae SARS-CoV-2,” “PASC,” “Pakistan,” and “South Asia.” No date restrictions were applied. Reference lists of identified studies were screened for additional publications.
Inclusion Criteria
For global prevalence estimates, we prioritized systematic reviews and meta-analyses published 2024-2025 synthesizing primary studies on Long COVID prevalence, risk factors, or outcomes. For Pakistan-specific evidence, we included all identified peer-reviewed studies examining Long COVID in Pakistani populations regardless of study design. For health system assessment, we drew on WHO country reports, published healthcare system analyses, and government documents.
Synthesis Approach
Given evidence heterogeneity and paucity of Pakistan-specific studies (fewer than ten identified), we employed narrative synthesis rather than meta-analytic methods. Global prevalence estimates were extracted from comprehensive recent meta-analyses. Pakistan-specific findings were synthesized thematically. Health system capacity was assessed using the WHO health system building blocks framework. Study limitations are discussed narratively rather than through formal quality scoring.
Burden Estimation
We applied global Long COVID prevalence estimates to Pakistan’s confirmed COVID-19 cases and estimated total infections to generate illustrative burden estimates. These extrapolations rest on assumptions detailed in the Results section and should be interpreted as order-of-magnitude estimates rather than precise epidemiological measures.
RESULTS
Evidence Synthesis: Burden and Manifestations
Recent meta-analyses suggest Long COVID affects approximately 36% of individuals with confirmed SARS-CoV-2 infection globally, though estimates vary considerably across studies and populations, with Asia showing approximately 35% prevalence [1]. Symptoms persist over extended periods, lasting one to two years in an estimated 46% of cases [1]. The most prevalent manifestations include respiratory symptoms, fatigue, psychological disturbances, and neurological complications, each affecting an estimated 16-20% of those infected [1]. Pakistan recorded approximately 1.58 million confirmed COVID-19 cases by April 2024 [3]. National seroprevalence survey data suggests actual infections may be nearly three times higher, indicating a true burden potentially exceeding 4.5 million cases [4]. Applying the conservative Asian prevalence estimate of 35% yields an illustrative range of approximately 550,000 to 1.6 million individuals potentially experiencing Long COVID symptoms.
Key assumptions underlying these estimates: (1) global prevalence estimates apply to Pakistani populations despite potential differences in viral variants, healthcare access, and demographics; (2) under-reporting ratios from national surveys accurately reflect true infection burden; (3) Long COVID risk is similar across hospitalized and non-hospitalized cases. Given these assumptions, these figures represent order-of-magnitude estimates highlighting plausible substantial burden rather than precise epidemiological measures. Comprehensive national surveillance data on Long COVID in Pakistan remains absent.
Limited Pakistan-specific research suggests concerning patterns. A twelve-month follow-up study at Aga Khan University Hospital documented 4.58% mortality following discharge among COVID-19 patients, with severe disease in 64% of hospitalized cases [5]. A multinational cross-sectional study including Pakistani participants found 25.1% reporting Long COVID symptoms six months post-infection [6]. These hospital-based studies likely underestimate community burden but confirm Long COVID presence in Pakistani populations.
Long COVID affects mental health and psychosocial wellbeing substantially. A cross-sectional study conducted in Islamabad examining Long COVID patients found significant correlations between COVID-19 symptoms and psychological variables, including negative associations with cognitive function and positive correlations with depression and anxiety [16]. Female patients were disproportionately affected, reporting significantly higher levels of depression and anxiety compared to males, underscoring the need for gender-sensitive mental health interventions in post-COVID care [16]. Another Pakistani study utilizing validated psychological scales found that Long COVID patients experience persistent symptoms affecting general health and psychosocial wellbeing, with participants demonstrating elevated scores on measures of depression, anxiety, and stress [17]. These findings reveal that the psychological burden of Long COVID in Pakistan extends far beyond what is currently recognized by the healthcare system, which lacks adequate mental health infrastructure to address these emerging needs.
A multinational cross-sectional study across 33 countries, including Pakistan, involving 11,801 PCR-confirmed COVID-19 patients identified 25 significant predictors of Long COVID development [18]. The study found a 19.8% prevalence of Long COVID globally, with the strongest risk factors being intensive care unit admission, female sex, acute-phase fatigue, Hispanic ethnicity, and pre-existing gastrointestinal disease [18]. Critically, the analysis demonstrated that receiving even a single dose of COVID-19 vaccination was associated with significantly lower odds of developing Long COVID, while African American and Asian ethnicities showed protective effects [18]. The most frequently observed symptoms included chest pain, shortness of breath, dysgeusia, insomnia, muscle and joint symptoms, fatigue, and gastrointestinal symptoms, affecting 23% to 30% of Long COVID patients [18]. These findings reinforce that vaccination remains a crucial preventive strategy against Long COVID, yet Pakistan’s vaccination coverage, particularly in rural areas, remains suboptimal, leaving substantial populations at elevated risk.
Neurocognitive sequelae represent an important dimension of Long COVID requiring attention in Pakistan. Research from Islamabad documented significant cognitive deficits among Long COVID patients, with Mini-Mental State Examination scores showing negative correlations with COVID-19 symptom severity [17]. The study revealed that cognitive impairment varied significantly by gender, COVID-19 severity, educational level, and age, with females and younger adults showing greater vulnerability to cognitive deficits [17]. Patients reported difficulties with memory, attention, concentration, and executive function—impairments that substantially affect work capacity, educational attainment, and daily functioning [17]. These cognitive impacts are particularly concerning in a young, economically active population where cognitive deficits translate directly into lost productivity and reduced quality of life. These findings suggest need for neuropsychological assessment protocols and cognitive rehabilitation services, which currently remain limited to major urban centers.
Health System Capacity Assessment
Pakistan’s healthcare infrastructure faces substantial constraints relevant to Long COVID response. The WHO ranks Pakistan 122nd among 191 countries in overall health system performance and 154th in the Healthcare Access and Quality Index [7,8]. Chronic underfunding, inadequate infrastructure, healthcare worker shortages, and limited rural access to specialized care characterize the system [9-11]. Primary healthcare facilities lack essential medications for chronic disease management, with availability rates falling far short of WHO requirements. The pandemic exacerbated these deficiencies, exposing critical gaps in testing capacity, personal protective equipment, and hospital beds. Healthcare workers faced unprecedented psychological stress without adequate mental health support systems.
Table 1 indicates that Pakistan lacks established rehabilitation services and multidisciplinary care teams necessary for Long COVID’s complex, multi-system nature. The few rehabilitation facilities primarily serve orthopedic and stroke patients, with no protocols for Long COVID-specific rehabilitation addressing cardiopulmonary, neurological, and psychological sequelae simultaneously. Patients with Long COVID navigate a fragmented system largely unequipped to recognize or treat their condition.
The country’s pluralistic healthcare landscape presents both challenges and opportunities. Traditional medicine practitioners (hakeems), spiritual healers, and homeopaths serve substantial patient populations. Effective Long COVID response must acknowledge this reality, providing guidance on potential interactions and engaging traditional practitioners as partners in awareness and referral rather than dismissing their role.
Lessons from Comparative Analysis
Examining Long COVID responses across countries with varying resource levels illuminates both gaps and opportunities for Pakistan. High-income countries including the United Kingdom, United States, and Canada have established dedicated Long COVID clinics, developed national clinical guidelines, implemented rehabilitation programs, and funded substantial research initiatives. The UK’s National Health Service created over 90 Long COVID assessment clinics within 18 months of pandemic onset, while the US RECOVER Initiative allocated over $1 billion for Long COVID research [12,13]. These responses, while exemplary, require infrastructure and resources unavailable to Pakistan.
Cross-country comparison reveals that effective Long COVID responses in resource-constrained settings share common features: adaptation of existing infrastructure rather than parallel system creation, task-shifting to community health workers, and integration with established programs.
Thailand’s response, despite similar GDP per capita to Pakistan, reflects stronger primary care infrastructure built since the 1970s, which are structural advantages enabling rapid Long COVID integration through existing networks [14]. Rwanda’s community health worker approach built on HIV/AIDS and maternal health platforms, demonstrating feasibility of task-shifting [15]. Brazil adapted telemedicine platforms developed during acute COVID response for Long COVID follow-up, extending reach to dispersed populations.
Pakistan possesses analogous structural assets: the Lady Health Workers program (over 100,000 workers), telemedicine platforms developed during COVID-19, and non-communicable disease programs that could integrate Long COVID screening. India has published substantially more Long COVID research despite similar constraints, reflecting institutional prioritization rather than inherently greater capacity.
The critical question is not what infrastructure Pakistan lacks but why existing assets remain unmobilized. Contributing factors likely include competing health priorities, limited policymaker awareness of Long COVID burden, and fragmented governance across federal and provincial health authorities. Pakistan’s devolved health system, with health as a provincial subject, creates coordination challenges requiring deliberate federal-provincial engagement.
Economic implications of inaction are potentially substantial. Global analyses estimate Long COVID may reduce GDP by approximately 1% [12]. For Pakistan (GDP approximately $375 billion), this suggests potential annual losses in the billions of dollars, though this extrapolation carries considerable uncertainty given differences in labor market structures, informal economy size, and social protection systems between Pakistan and the high-income countries where these estimates originate. Health economics research specific to Pakistan is needed to quantify actual impacts.
DISCUSSION
Policy Framework and Implementation Considerations
The economic and social costs of unaddressed Long COVID in Pakistan could be catastrophic. Long COVID has been estimated to reduce global gross domestic product by approximately 1%, with the burden falling disproportionately on countries with limited healthcare capacity [12]. Pakistan, with an economically vulnerable population and limited social safety nets, faces particular risk.
National Surveillance
Establishing surveillance to quantify Long COVID burden across populations is foundational. Current evidence relies on hospital-based studies missing non-hospitalized patients who represent the largest affected population. Population-based surveys using standardized WHO definitions are needed [15]. Implementation could leverage Pakistan’s existing Disease Early Warning System infrastructure, adding Long COVID as a reportable condition with case definitions adapted to available diagnostic capacity. Mobile phone-based surveillance, building on COVID-19 contact tracing applications, offers a scalable mechanism for symptom tracking.
Implementation considerations: Surveillance requires coordination across Pakistan’s devolved health system. Success depends on federal-provincial agreement on standardized definitions, resource allocation within constrained provincial budgets, and training for existing surveillance staff. The National Institute of Health could coordinate provincial efforts while respecting federal structure.
Clinical Guidelines
Comprehensive Long COVID clinical guidelines adapted to Pakistan’s context should cover diagnostic criteria feasible without advanced imaging, symptom-based management using available medications, and referral pathways for complicated cases. Guidelines should emphasize primary care-level management to avoid overwhelming tertiary facilities.
Guidelines must address the substantial role of traditional and alternative medicine in Pakistani healthcare-seeking behavior. Rather than dismissing traditional practices, guidelines could identify approaches that are benign or potentially supportive, clearly communicate contraindications, and position traditional practitioners as partners in awareness and referral.
Implementation considerations: The Pakistan Medical and Dental Council could lead guideline development with relevant specialty societies. Telemedicine protocols would enable remote consultation, reducing travel burden for rural patients. Stigma surrounding COVID-19 infection in Pakistani communities requires attention; guidelines should incorporate confidential screening pathways and community education emphasizing that Long COVID affects previously healthy individuals.
Rehabilitation Infrastructure
Long COVID requires integrated care involving pulmonologists, cardiologists, neurologists, psychiatrists, and rehabilitation therapists—specialties concentrated in major urban centers. Expanding services to district level requires strategic task-shifting to mid-level providers and community health workers.
The Lady Health Workers program offers an existing platform for community-level Long COVID identification, basic symptom management, and referral. Training curricula should emphasize symptom recognition, mental health first aid, breathing exercises and energy conservation techniques teachable to patients and families, and referral criteria. District hospitals could establish basic multidisciplinary clinics with telemedicine links to provincial tertiary centers.
Implementation considerations: Rehabilitation need not require expensive equipment; evidence-based programs emphasizing graded exercise, breathing techniques, and cognitive behavioral approaches can be delivered in community settings. Gender-sensitive implementation is essential—female patients face mobility constraints and may require household-based assessment. The Lady Health Workers program, composed of women serving women and children, is well-suited to gender-sensitive outreach.
Prevention Through Vaccination
Being unvaccinated approximately doubles Long COVID odds compared to vaccination [1,14]. Pakistan’s vaccination coverage requires strengthening, particularly in rural and underserved communities where hesitancy and access barriers persist. Full vaccination coverage remains below 60% with substantial provincial disparities.
Implementation considerations: Targeted campaigns should address specific concerns of under-vaccinated populations including religious communities, rural women with mobility constraints, and urban informal sector workers. Public communication about Long COVID risks may motivate preventive behaviors. Mosque-based health education and school-based awareness programs could emphasize that Long COVID affects young, previously healthy individuals.
Research Priorities
Pakistan requires longitudinal studies following COVID-19 survivors to understand Long COVID natural history in local populations [5]. Research should investigate genetic, environmental, and social determinants that may modify risk in South Asian populations and examine intersection with Pakistan’s high burden of non-communicable diseases [14,18].
Priority areas include prospective cohorts across diverse settings to capture true epidemiology beyond hospital samples; validation of assessment instruments in Urdu and regional languages; health economics research quantifying direct costs and productivity losses; and implementation science evaluating feasibility of community health worker models and telemedicine platforms.
International research partnerships can provide technical support while building local capacity. Pakistan’s medical universities should prioritize Long COVID in faculty development and student training. The Pakistan Health Research Council could establish dedicated funding to catalyze investigator-initiated studies.
Methodological Considerations and Limitations
This analysis has several important limitations that should inform interpretation.
Evidence quality: We employed narrative synthesis rather than systematic review methodology. While we conducted comprehensive searches, we did not apply pre-registered protocols, dual screening, or formal risk of bias assessment. The paucity of Pakistan-specific studies (fewer than ten identified) precluded meta-analysis.
Pakistan-specific study constraints: Available studies are predominantly cross-sectional, hospital-based, and drawn from urban tertiary centers in Islamabad and Karachi. Sample sizes are modest, potentially introducing selection bias toward more severe cases. Observational designs preclude causal inference. Community-dwelling, non-hospitalized Long COVID cases remain largely uncharacterized.
Uncertainty in burden estimates: National estimates are extrapolations carrying substantial uncertainty. If Asian-specific prevalence ranges from 25% to 46% and accounting for uncertainty in true infection burden (1.5-4.5 million), the plausible range spans approximately 375,000 to over 2 million individuals. This wide range reflects genuine epistemic uncertainty. Economic impact estimates derived from high-income country analyses may not translate directly to Pakistan’s context.
Generalizability: Gender, ethnic, and linguistic diversity within Pakistan is inadequately represented in existing research. Proposed interventions require adaptation across Pakistan’s diverse provinces and administrative contexts.
These limitations underscore the urgency of establishing systematic surveillance and research infrastructure rather than invalidating the policy directions proposed.
CONCLUSIONS
The COVID-19 pandemic revealed Pakistan’s healthcare vulnerabilities but also demonstrated capacity for rapid response when political will exists. Long COVID requires similar determination. The affected population includes economically productive adults supporting families and contributing to national development. Allowing Long COVID to persist unaddressed risks long-term disability burden, strained healthcare resources, and widened health inequities.
Pakistan’s federal and provincial health authorities should acknowledge Long COVID as a public health priority and allocate resources for surveillance and care. Academic institutions should establish research programs building on existing infrastructure. International partners should provide technical and financial support, recognizing that pandemic preparedness includes post-acute sequelae management.
The framework proposed here—based on surveillance leveraging existing infrastructure, adapted clinical guidelines emphasizing primary care, community-based rehabilitation building on proven platforms, and prevention through vaccination—offers a feasible pathway. Implementation requires strategic adaptation of existing resources, political commitment, and recognition that pandemic response extends beyond acute illness management. This approach may inform Long COVID responses across low- and middle-income countries facing similar challenges.
Acknowledgements
None.
Ethics statement
Not applicable. This is a policy analysis based on published literature. No primary data were collected.
Data availability
All data relevant to the study are included in the article. This analysis synthesizes publicly available published research.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Authorship contributions
FAC is the sole author responsible for conception, design, evidence synthesis, analysis, interpretation, drafting, critical revision, and final approval of this work.
Disclosure of interest
The author completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and discloses no relevant interests.
Author Note
FAC is a PhD candidate in Rehabilitation Sciences at the Department of Occupational Science and Occupational Therapy, University of British Columbia (UBC), originally from Pakistan, researching Long COVID in BC, health systems strengthening and pandemic preparedness.
Positionality Statement
The author’s perspective is informed by positioning as a Pakistani researcher training in a high-income country health system. This provides comparative insight into health system responses but may introduce bias toward frameworks developed in well-resourced settings. Recommendations were developed with attention to contextual adaptation and feasibility in resource-constrained settings.
Correspondence to:
Farrukh A. Chishtie
Department of Occupational Science and Occupational Therapy
University of British Columbia
Vancouver, British Columbia, Canada