Should health experts and scientists have taken control of COVID-19 response nationally and globally from the very beginning? People with expertise in epidemiology, infectious diseases, etc. seem to be in the best position to model the health impact of the disease, understand the infection mechanisms and prescribe interventions. The prescribed response from most experts in the context of the COVID19 pandemic is a mix of long-term social isolation, city-wide shutdowns, quarantine of communities, or even entire cities.
If this is the most appropriate response then the experience from the past few months raises a few important questions:
- Why are political leaders spearheading the response?
- Why did we see significant variations, at least in the initial response across the world?
- And more recently, why are we seeing a wide spectrum of responses in the re-opening of communities and countries?
Decision-making in the context of trade-offs
As evident, most health decisions carry a significant amount of economic and social costs. There are also indirect health impacts such as mental health issues like increasing loneliness, depression, etc. Others such as domestic violence may carry significant long-term impacts on vulnerable sections like mothers and children. Then there are the economic impacts of unemployment, an increase in delinquency, stressed income, etc. This leads to a situation where we have experts with different specialization working with an array of problems which in themselves are multi-dimensional. But an expert works within defined boundaries of expertise. Thereby experts may not be in the best position to make immediate inter-sector or cross-domain trade-offs and prescribe solutions without following the scientific decorum of consistency and validity.
On the other hand, a democratic political process by design involves multiple stakeholders. At the very least, the politicians have experience in arbitrating between different viewpoints. However, due to the varying political scene and setups across the world, it is not surprising that the actions have significantly reflected the local context and leadership of each country. In addition to this, the working structure of the organization also plays a critical role in devising the strategy. Three dimensions of the structure are said to define an organization’s strategy: Centralization, Formalization, and Complexity. A high degree of centralization would mean that the comprehensiveness of a response will depend on the cognitive limitations of top leadership, who then require complete information to make the trade-offs. Whereas a high degree of formalization of functions results in slow response due to its reliance on following standard organizational processes. And highly complicated organization are more likely to regress to parochial preferences when a decision has to be taken within a large constraint set.
How are leaders making these political trade-offs?
- Impact of public perceptions
Trade-offs are usually made by weighing questions like: “What is the economic or social cost of shutting down the country Vs What is the public health cost of shutting down that may not be related to a pandemic?” In most cases, this data is not available. Even the public health models acknowledge a significant amount of variation based on assumptions around economic and health baselines. In the absence of clear definite models, we can expect a strong reliance on anticipated public response i.e. “How might my response be received by the public?”. This is especially the case when there is high coupling between the political-process and public perception.
2. Misaligned criteria
Larry Kudlow, National Economic Council Director, in an interview with Fox News said “ the cure can’t be worse than the disease”, aligning himself to the President’s view that lockdown restrictions may be relaxed to keep the economy afloat. Whereas Dr.Fauci, Director of the National Institute of Allergy and Infectious Diseases, who has been the face of the COVID19 task force, continues to recommend extreme health preventive measures. Trade-offs for the president and his economic advisor stem from the immediate need to minimize short-term economic losses and that of Dr.Fauci and other experts, the need to minimize short term health losses, leading to misalignment in response. Hence setting a common frame of reference improves the overall direction of the pandemic response.
3. Impact of “who” captures the risk
The origin of response has varied hugely across the world. In India, where state governments had been more proactive to impose longer lockdowns, the national government was able to chalk out an aggressive response in extending it to the entire nation. Contrast it to the situation in the US, where the governors have responded differently, the federal response has been more reactive and delayed.
It looks as if the local institutions play a critical role in creating the necessary space for risk appetite. For instance, as the urgency displayed by many mayors by raising the alarm for their communities. Prompting a more cooperative behavior among the citizens of these communities. Thus, a sub-national level response seems to increase the risk internalization among the public. Once they have captured and digested the risk, the national leader or the central/federal government can then take stricter decisions in line with expert opinions.
How are leaders defining the pandemic?
Creating a relevant pandemic persona is important to help leaders make the necessary trade-offs. Following dimensions seem to be showing up across the world:
- Period of Interaction: The Indian Prime Minister said that if India does not manage the lockdown for these 21 days then India will be pushed back by 21 years. Such frames can help in setting proper time horizon frames (days vs years) for pandemic response.
- The Primary Victim: Italy’s quarantine measures initially were more locally defined and restricted to northern provinces only. This was followed by segregation of the country into red, yellow, and rest of the nation zones. Defining a pandemic as a localized emergency rather than a national emergency decreases the appetite for taking long-term risk assessments of the pandemic.
- Source of Response: Response stemming from the county/states and then moving up to the federal or central level generated among the citizens shared beliefs about the contagion and reduced the temporal distance of the risks associated with the pandemic. Places, where the response is driven at a local level, seem to internalize risks better.
How might we help the political process and what kind of systems are needed to make effective trade-offs?
Given the dynamic nature of the pandemic, how might we make the process more adaptive and enable the leadership to be agile and responsive? A pandemic presents a varying number of issues/trade-offs that may be intra-health, multi-sectoral (health, finance, transportation, tourism) and involve multiple stakeholders (national and sub-national), in a highly accelerated dynamic and often degenerative environments.
- The breadth of the response of any system needs to match the issue to be effective. The system needs to create information channels for effective risk uptake and propagation. Decentralized and collaborative systems are needed to capture local risks and constraints at a state/county level. These systems can then provide the central leadership with the set of optimal solutions. Early warning and response systems at a national level that can capture these different scenarios with matching responses can be used to guide sub-national teams towards capacity development.
- In order to build adequate human resources, systems can assist in building nation-wide strategic reserves. This could be done by identifying and storing details of personnel across the country who could be freed to absorb the stress on health workers. From a supply-chain point of view, systems could aim to reduce inter-state competitiveness and build inter-state cooperation by greater access and transparency on reserves to make service delivery locally responsive. The role of central leadership will then be to keep track of the changes that take place within this set
- Institutionalizing a simple multi-disciplinary pandemic response task force can create necessary capacity and agility in decision making with less formalization and more objectivity
- To ensure effectiveness in communicating the information to the public, a policy team can research appropriate framing techniques that lead to effective behavior change.
- A robust adaptive systems approach will help in building competency of rapid experimentation too and not modeling alone, and the results of which will be crucial while making the trade-offs in uncertain environments.
It has been widely agreed that structure can drive strategy, and it’s not just the other way round. Government organization’s structural preparedness thus becomes a crucial first step as we start thinking of the next pandemic or shock. Creating an appropriate organizational personality will help us understand and address key firm behaviors during a crisis.
Final Mile brings unique and proven capabilities in addressing complex behavioral challenges. As one of the first Behavioral Science & Design consultancies, Final Mile has had the opportunity to bring these to practice in a wide variety of sectors and contexts. We have executed highly complex behavior change projects across a wide variety of areas covering Global Health (HIV, TB, Maternal Health, WASH), Financial Inclusion, Safety across Africa, Asia, Europe, and the US.
Final Mile is also building a pandemic playbook that can be used as a potential toolkit by policymakers and implementors in mitigating Covid19 and future such pandemics.
Reach out to us at firstname.lastname@example.org.