Singapore's COVID-19 crisis decision-making through centralization, legitimacy, and agility: an empirical analysis.

Background: Decision-making during health crises differs from routine decision-making and is constrained by ambiguity about evolving epidemiological situations, urgency of response, lack of evidence, and fear. Recent analyses of governance and decision-making during COVID-19, focusing on leadership qualities, involvement of specific stakeholders, and effective resource management, do not adequately address a persisting gap in understanding the determinants of decision-making during health crises at the national level. Methods: We undertook a study to understand the processes and characteristics of decision-making during the COVID-19 pandemic in Singapore. We used a case study approach and collected empirical evidence about public health decision-making, using a combination of key informant interviews and focus group discussions with stakeholders from government, academia and civil society organizations. Findings: We argue that administrative centralization and political legitimacy played important roles in agile governance and decision-making during the pandemic in Singapore. We demonstrate the role of the Singapore government's centralization in creating a unified and coherent governance model for emergency response and the People's Action Party's (PAP) legitimacy in facilitating people's trust in the government. Health system resilience and financial reserves further facilitated an agile response, yet community participation and prioritization of vulnerable migrant populations were insufficient in the governance processes. Interpretation: Our analysis contributes to the theory and practice of crisis decision-making by highlighting the role of political and administrative determinants in agile crisis decision-making. Funding: This study is funded by the U.S. Centers for Disease Control and Prevention through a Cooperative Research Agreement (NU2HGH2020000037).

A pandemic agreement is within reach.

At the end of May, 194 member states of the World Health Organization (WHO) will meet for the World Health Assembly. Negotiations underway now will determine whether they vote then to adopt a pandemic agreement. For the past 2 years, discussions have focused on articulating essential components of a robust and equitable architecture for pandemic preparedness and response. Despite this, talks have failed to produce sufficient consensus on a detailed draft, prompting the intergovernmental negotiating body to propose a "streamlined" version. The new text, released on 16 April, consolidates provisions for research and development, technology transfer, pathogen access and benefit sharing (including pandemic products such as medicines and vaccines), with many particulars deferred to future procedures. Ultimately, success of the agreement will depend on these details and implementation. Nevertheless, member states shouldn't bypass the consensus reached to date, but continue progress to adopt this agreement.

Governance and Public Health Decision-Making During the COVID-19 Pandemic: A Scoping Review.

Objective: We provide an in-depth understanding of how governance and decision-making during the COVID-19 pandemic has been empirically characterized in the literature to identify gaps in research and highlight areas that require further inquiry. Methods: We searched peer-reviewed publications using empirical data published between Jan 1, 2020 and Jan 31, 2022 in three electronic databases to examine the process of governance and decision-making during the COVID-19 pandemic. Two authors independently screened the records and 24 publications were extracted for the review. Results: Governance is analyzed by its level at national, sub-national, community and by its aspects of process, determinants and performance. While different methodological approaches are used, governance is conceptualized in four ways 1) characteristics and elements, 2) leadership, 3) application of power and 4) models or arrangements of governance. Conclusion: For future pandemic preparedness, there is a need for more empirical research using a unified conceptual approach to governance, which integrates decision-making processes and can guide governance structures and mechanisms across different countries and contexts. We call for more inclusivity in who performs the research on governance and where.

National and subnational governance and decision-making processes during the COVID-19 pandemic in Nigeria: an empirical analysis.

Governance of the COVID-19 pandemic required decision-makers to make and implement decisions amidst uncertainty, public pressure and time constraints. However, few studies have attempted to assess these decision-making processes empirically during health emergencies. Thus, we aimed to understand governance, defined as the process of decision-making and implementation of decisions, during the COVID-19 pandemic in Nigeria. We conducted key informant interviews and focus group discussions with national and subnational government officials, civil society organisation (CSO) members, development partners and academic experts. Our study identified several themes on governance and decision-making processes. First, Nigeria established high-level decision-making structures at the federal and state levels, providing clear and integrated multisectoral decision-making mechanism. However, due to the emergence of conflicts between government levels, there is a need to strengthen intergovernmental arrangements. Second, while decision-makers relied on input from academic experts and CSOs, additional efforts are required to engage such stakeholders in decision-making processes, especially during the early stages of health emergencies. Third, Nigeria's previous experiences responding to disease outbreaks aided the overall response, as many capacities and coordination mechanisms for cohesive action were present. Fourth, while decision-makers took a holistic view of scientific, social and economic factors for decision-making, this process was also adaptive to account for rapidly evolving information. Lastly, more efforts are needed to ensure decisions are inclusive, equitable and transparent, and improve overall public trust in governance processes. This study provides insights and identifies opportunities to enhance governance and decision-making processes in health emergency responses, aiding future pandemic preparedness efforts.

Decolonization of Global Health Law: Lessons from International Environmental Law.

Global health law for pandemics currently lacks legal obligations to ensure distributional and reparative justice. In contrast, international environmental law contains several novel international legal mechanisms aimed at addressing the effects of colonialism and global injustices that arise from the disproportionate contributions to - and impacts of - climate change and biodiversity loss.

Open data for COVID-19 policy analysis and mapping.

As the COVID-19 pandemic unfolded in the spring of 2020, governments around the world began to implement policies to mitigate and manage the outbreak. Significant research efforts were deployed to track and analyse these policies in real-time to better inform the response. While much of the policy analysis focused narrowly on social distancing measures designed to slow the spread of disease, here, we present a dataset focused on capturing the breadth of policy types implemented by jurisdictions globally across the whole-of-government. COVID Analysis and Mapping of Policies (COVID AMP) includes nearly 50,000 policy measures from 150 countries, 124 intermediate areas, and 235 local areas between January 2020 and June 2022. With up to 40 structured and unstructured characteristics encoded per policy, as well as the original source and policy text, this dataset provides a uniquely broad capture of the governance strategies for pandemic response, serving as a critical data source for future work in legal epidemiology and political science.

Expanding global vaccine manufacturing capacity: Strategic prioritization in small countries.

The COVID-19 pandemic highlighted significant gaps in equitable access to essential medical countermeasures such as vaccines. Manufacturing capacity for pandemic vaccines, therapeutics, and diagnostics is concentrated in too few countries. One of the major hurdles to equitable vaccine distribution was "vaccine nationalism", countries hoarded vaccines to vaccinate their own populations first which significantly reduced global vaccine supply, leaving significant parts of the world vulnerable to the virus. As part of equitably building global capacity, one proposal to potentially counter vaccine nationalism is to identify small population countries with vaccine manufacturing capacity, as these countries could fulfill their domestic obligations quickly, and then contribute to global vaccine supplies. This cross-sectional study is the first to assesses global vaccine manufacturing capacity and identifies countries with small populations, in each WHO region, with the capacity and capability to manufacture vaccines using various manufacturing platforms. Twelve countries were identified to have both small populations and vaccine manufacturing capacity. 75% of these countries were in the European region; none were identified in the African Region and South-East Asia Region. Six countries have facilities producing subunit vaccines, a platform where existing facilities can be repurposed for COVID-19 vaccine production, while three countries have facilities to produce COVID-19 mRNA vaccines. Although this study identified candidate countries to serve as key vaccine manufacturing hubs for future health emergencies, regional representation is severely limited. Current negotiations to draft a Pandemic Treaty present a unique opportunity to address vaccine nationalism by building regional capacities in small population countries for vaccine research, development, and manufacturing.

Addressing the challenges of implementing evidence-based prioritisation in global health.

Global health requires evidence-based approaches to improve health and decrease inequalities. In a roundtable discussion between health practitioners, funders, academics and policy-makers, we recognised key areas for improvement to deliver better-informed, sustainable and equitable global health practices. These focus on considering information-sharing mechanisms and developing evidence-based frameworks that take an adaptive function-based approach, grounded in the ability to perform and respond to prioritised needs. Increasing social engagement as well as sector and participant diversity in whole-of-society decision-making, and collaborating with and optimising on hyperlocal and global regional entities, will improve prioritisation of global health capabilities. Since the skills required to navigate drivers of pandemics, and the challenges in prioritising, capacity building and response do not sit squarely in the health sector, it is essential to integrate expertise from a broad range of fields to maximise on available knowledge during decision-making and system development. Here, we review the current assessment tools and provide seven discussion points for how improvements to implementation of evidence-based prioritisation can improve global health.

The World Health Organization's Disease Outbreak News: A retrospective database.

The World Health Organization (WHO) notifies the global community about disease outbreaks through the Disease Outbreak News (DON). These online reports tell important stories about both outbreaks themselves and the high-level decision making that governs information sharing during public health emergencies. However, they have been used only minimally in global health scholarship to date. Here, we collate all 2,789 of these reports from their first use through the start of the Covid-19 pandemic (January 1996 to December 2019), and develop an annotated database of the subjective and often inconsistent information they contain. We find that these reports are dominated by a mix of persistent worldwide threats (particularly influenza and cholera) and persistent epidemics (like Ebola virus disease in Africa or MERS-CoV in the Middle East), but also document important periods in history like the anthrax bioterrorist attacks at the turn of the century, the spread of chikungunya and Zika virus to the Americas, or even recent lapses in progress towards polio elimination. We present three simple vignettes that show how researchers can use these data to answer both qualitative and quantitative questions about global outbreak dynamics and public health response. However, we also find that the retrospective value of these reports is visibly limited by inconsistent reporting (e.g., of disease names, case totals, mortality, and actions taken to curtail spread). We conclude that sharing a transparent rubric for which outbreaks are considered reportable, and adopting more standardized formats for sharing epidemiological metadata, might help make the DON more useful to researchers and policymakers.

Pandemic preparedness and response: exploring the role of universal health coverage within the global health security architecture.

In response to the COVID-19 pandemic, several international initiatives have been developed to strengthen and reform the global architecture for pandemic preparedness and response, including proposals for a pandemic treaty, a Pandemic Fund, and mechanisms for equitable access to medical countermeasures. These initiatives seek to make use of crucial lessons gleaned from the ongoing pandemic by addressing gaps in health security and traditional public health functions. However, there has been insufficient consideration of the vital role of universal health coverage in sustainably mitigating outbreaks, and the importance of robust primary health care in equitably and efficiently safeguarding communities from future health threats. The international community should not repeat the mistakes of past health security efforts that ultimately contributed to the rapid spread of the COVID-19 pandemic and disproportionately affected vulnerable and marginalised populations, especially by overlooking the importance of coherent, multisectoral health systems. This Health Policy paper outlines major (although often neglected) gaps in pandemic preparedness and response, which are applicable to broader health emergency preparedness and response efforts, and identifies opportunities to reconceptualise health security by scaling up universal health coverage. We then offer a comprehensive set of recommendations to help inform the development of key pandemic preparedness and response proposals across three themes-governance, financing, and supporting initiatives. By identifying approaches that simultaneously strengthen health systems through global health security and universal health coverage, we aim to provide tangible solutions that equitably meet the needs of all communities while ensuring resilience to future pandemic threats.

A treaty to break the pandemic cycle.

An evidence-based treaty must balance prevention, preparedness, response, and repair.

International law reform for One Health notifications.

Epidemic risk assessment and response relies on rapid information sharing. Using examples from the past decade, we discuss the limitations of the present system for outbreak notifications, which suffers from ambiguous obligations, fragile incentives, and an overly narrow focus on human outbreaks. We examine existing international legal frameworks, and provide clarity on what a successful One Health approach to proposed international law reforms-including a pandemic treaty and amendments to the International Health Regulations-would require. In particular, we focus on how a treaty would provide opportunities to simultaneously expand reporting obligations, accelerate the sharing of scientific discoveries, and strengthen existing legal frameworks, all while addressing the most complex issues that global health governance currently faces.