By Dara Carr
“No single individual, discipline, sector or ministry can preempt and solve complex health problems.”
— Rwanda One Health Steering Committee
The COVID-19 pandemic underscores the importance of multisectoral action to contain and mitigate the effects of the virus. Presently, during crisis conditions or “war time,” in the language of outbreak experts, multisectoral efforts—including actions traversing health, education, labor, finance and other sectors—are readily apparent. But when policymakers perceive crises have passed, during so-called “peacetime,” governance structures that enable multisectoral collaboration tend to diminish or languish.
While countries continue their COVID-19 pandemic “war time” efforts, it is critical to highlight the importance and benefits of multisectoral collaboration so that when the pandemic is past, they will sustain the momentum in planning and coordination that has emerged. This type of ongoing collaboration is key to address the rising risks posed by emerging infectious diseases. Most disease threats are zoonotic (transmitted between animals and humans), and the forces that drive contact between animals and people, such as population growth, habitat encroachment, livestock intensification, and changes in land use, are increasing. In the past three decades, scientists estimate that new diseases affecting humans have emerged at the rate of at least one per year. Thus, it is not a question of if but when another pandemic threat will occur—reinforcing the need for ongoing preparedness.
Zoonotic diseases have been behind the most lethal pandemics in recorded human history. Critically, multisectoral collaboration can facilitate a more forward-leaning orientation toward these diseases. Infection among animals, for example, could presage an outbreak among humans. Thus, collaboration among animal and human health workers could mean early intervention at the animal “source” or soon thereafter, reducing the risk of a major outbreak. Recognizing the importance of multisectoral collaboration, many countries have made impressive efforts to operate in less siloed ways. As part of the Preparedness & Response project (2014-2019), which was funded by the U. S. Agency for International Development, Palladium (then also known as Futures Group) worked with countries interested in establishing and strengthening multisectoral mechanisms to address emerging infectious diseases. The 16 countries receiving project support made important strides. In spite of progress, we observed some common barriers to strengthening and sustaining this type of collaboration:
A “boom-bust” pattern of funding and priority. Outside of outbreaks, multisectoral governance entities typically lack adequate funding for staff and activities, adversely affecting forward-leaning planning, including harmonizing disease-specific plans across sectors, engaging in simulations and after-action reviews, and forging working relationships across sectors. Often, in our view, government strategies for greater multisectoral collaboration were not implemented due to a lack of political will as well as resources. Stakeholders expressed the need to develop and implement strategies to keep emerging infectious diseases on the policy agenda during “peacetime”—reinforcing the importance of creative messaging and thinking to sustain funding and collaboration.
Inadequate anchoring within government. Multisectoral governance mechanisms are often best positioned to convene across sectors, secure resources, and influence policy when situated at higher levels of government, such as the Office of the Prime Minister, and backed by an act of law. In practice, multisectoral structures may exist due to a memorandum of understanding between two ministries, or be a sub-program within a division, undermining their convening power and ability to secure a budget line item. While Palladium worked on the Preparedness & Response project, stakeholders recognized the importance of high-level visibility and coordination, and frequently asked for support to help make the case to shift institutional arrangements to better enable and safeguard multisectoral action.
Uneven engagement across sectors. Often, not all relevant stakeholders across sectors participate in collaborative efforts. In part, this may be due to differential resourcing. Government programs in environment, for instance, tend to be especially under-funded and under-staffed. Ministries may not prioritize participation due to differing priorities. For example, the Ministry of Agriculture’s leadership might be most focused on the economics of animal production and trade and grant less priority to animal health in terms of its links to pandemic threats and human health. Long-term planning and budgeting are needed to ensure the right government offices are at the table to respond to these types of complex crises.
Lack of effective messaging and evidence for high-level decisionmakers. Typically, competing priorities and high turnover among leaders mean that collaboration champions need to bring their issues to the attention of senior decisionmakers on a regular basis. Technical personnel may face challenges in synthesizing and communicating evidence to the latest high-level decisionmakers. Also, senior officials may pose questions that require specialized analyses to answer questions that seek to justify additional funding, such as: Where do emerging infectious diseases rank in terms of other illnesses (e.g., HIV, tuberculosis, malaria)? What is the return on investment of multisectoral actions? What are the potential costs of inaction?
Existing policy assessment and advocacy approaches can be readily adapted to help address these barriers. Decades of experience in family planning and HIV have produced a rich body of proven approaches and tools (for example, Advance Family Planning’s advocacy resources or this comprehensive advocacy training manual). Palladium’s work in the Preparedness & Response project included facilitating participatory workshops in advocacy strategy development and action planning (see project toolkits). These activities helped stakeholders move beyond vague aims, such as “sensitizing” decisionmakers, to defining specific, measurable, achievable, relevant, and timebound objectives; and translating strategic priorities into action plans. For instance, stakeholders aiming to increase domestic funding for multisectoral action went on to map budget processes to identify entry points for influence, develop a concept note, and engage directly with key finance and other officials.
Policy models can generate the type of evidence needed to engage effectively with high-level decisionmakers. Projections and scenarios can help address a core concern, namely: given other pressing priorities, what is a reasonable level of investment to address intermittent or currently unknown diseases with potentially catastrophic effects? These data can also enable collaboration champions, typically steeped in morbidity and mortality metrics, to frame issues in policy-friendly ways, emphasizing potential health outcomes as well as economic losses or gains associated with different courses of action.
Despite the importance of policy-related capacities, few multisectoral governance mechanisms addressing emerging infectious diseases have budgets that include staff or consultants with this type of expertise. To better support multisectoral action, global or national initiatives would be well-served to consider the need for staff expertise and capacity strengthening in areas such as coalition building, stakeholder engagement, strategic communications, and policy modeling. Amid a pandemic, under “war time” conditions, the time is ripe to sustain strong ongoing multisectoral collaboration and reduce the risk of future disease threats.
Dara Carr is a director for health at Palladium, where she has contributed technical leadership on several USAID-funded health policy and preparedness and response projects.
Sources: Johns Hopkins Bloomberg School of Public Health’s Gates Institute for Population and Reproductive Health, The Lancet, Palladium, PLOS, Rwanda One Health Steering Committee, The Solutions Journal, USAID, World Bank