By Daniela C. Rodríguez, Benjamin Uzochukwu, Rhona Mijumbi, Mamadou Samba, Nasreen Jessani
The ecosystem around Evidence-Informed Decision-Making (EIDM) has been growing steadily in Africa over the years. We have seen more individuals, organizations and governments paying attention to evidence for their policies. This seems to have been accelerated – both positively as well as negatively – during COVID-19.
Health researchers have been thrust into the center of decisions during the COVID-19 pandemic crisis like never before. One critical role they play is that of interpreting available evidence, combining it with their knowledge of the local health systems in their context, and collaborating with policymakers to decide next steps. Simply put, researchers are rapidly localizing public health evidence for COVID-19 decision-making. They are also trying to balance the challenges and opportunities for providing evidence for COVID-19 decision-making when health is in conflict with economic as well as social strife.
How well is the system working? How are researchers navigating competing demands to support the COVID response? How is the situation affecting researchers personally? A webinar ‘Evolving evidence, fake news, and emerging contexts: researchers at the nexus of EIDM for COVID-19‘ co-hosted by the Africa Evidence Network (AEN) and the Translating Evidence to Action Thematic Working Group of Health Systems Global delved into the experiences of three African researchers as they support an EIDM in COVID-19 response in Cote d’Ivoire, Nigeria and Uganda.
The complexity of EIDM in times of COVID-19
All three panelists reflected that the typical peer-reviewed evidence for COVID-19 has been rapidly evolving, so clear answers are not always available. Also, given that COVID-19 is more than a medical problem and has social, economic and cultural implications, it is critical for EIDM endeavors to incorporate lessons from other countries as well as incorporate informal evidence from local communities about the local context. Experiences with the 2014 Ebola outbreak, for example, have provided significant lessons for African countries to draw upon. Interestingly, both Nigeria and Uganda had been affected by Ebola, but panelists described very different approaches to how those learnings affected the COVID-19 response in their countries.
To answer questions like “How will our population manage public health measures like lockdowns or distancing?” decision-makers need the tacit knowledge from past experiences and they must be deliberate in seeking this out. The panelists reflected that trust in government really influences how communities react to governments’ actions. Informal evidence gives you examples of where communities do or do not follow government guidance, but community engagement is also critical to reaching citizens and addressing their concerns.
There is a recognition that, especially early on, engagement with citizens in defining the COVID-19 response has been lacking. Uganda and Cote D’Ivoire have made efforts to connect with civil society organizations (CSOs) who have experience with strong citizen engagement as a way to bring in citizen input and highlight the implications of public health measures on the population, such as the impact of curfews on informal workers. Cote D’Ivoire has also engaged CSOs in supporting the response by modeling good public health practice.
The timeliness of decision-making has also been critical. Dr Mijumbi noted that in Uganda, the President, using military illustration, stressed that “when you are in battle and are in enemy territory or suspect they are somewhere near, your commander will usually ask you to stop moving and listen. In that way you are able to work out which side they might approach you from.” It is the same during lockdown – Ugandan response teams were able to monitor and zero-in on truck drivers contributing to superspreading events leading to an immediate closure of borders.
Governance structures to support COVID-19 EIDM
In all three countries, specific structures were created to support EIDM. In early May, coinciding with plans to ease lockdowns, the federal Ministry of Health in Nigeria established the Ministerial Expert Advisory Committee on COVID-19 Health Sector Response (MEACoC-HSR), consisting of eminent Nigerian scientists in public health, virology and infectious disease, to assist decision-making within the Ministry. The committee was challenged to use scientific expertise and seek necessary evidence in order to “flatten the curve” without flattening the economy. The Association of Public Health Physicians of Nigeria (APHPN), which has members in all states who are part of rapid-response teams and emergency operation centres at federal and state levels, has argued that locally tailored measures are needed and have supported knowledge sharing across states to implement control strategies.
In Cote D’Ivoire, when the WHO declared the novel coronavirus a pandemic, the government, through the Ministry of Health, reactivated its emergency operations center and put in place a COVID-19 surveillance plan. This made it possible to detect the first positive case very early, on March 11, 2020. The first case led to the creation of a five-person decision-making committee to draw up the national plan: a heavy responsibility. Thus, the capital Abidjan, epicenter of the disease with more than 90 per cent of cases, was isolated from the rest of the country and all cases in the interior of the country were brought back to Abidjan for care and follow-up. Early on there was fear because they lacked information to inform their decisions, which led to some cautious advancement. However, with time, this has led to important decisions on locally appropriate measures (e.g. masks but no lockdown). Much of these decisions were guided by lessons learned from regular outbreaks of other disease in West Africa
Uganda has a National Taskforce, and similar to Nigeria, smaller task forces feed into it. For example, the Uganda Medical Association (UMA) has its own taskforce and smaller ones for pertinent issues, like the one handling PPE because this is at the heart of the welfare of doctors – UMA’s mission. The UMA will also have representation on the National Taskforce to align UMA’s input into the decision-making process. Because of this alignment of decision-making, the controversies are few and have been quickly addressed.
Pressures on researchers
While there is a growing cadre of public health and health systems researchers in Africa, there still is not a deep bench of professionals already plugged into policymaking and decision-making processes that can be called on in times of crisis. The researchers that policymakers turned to before the crises have become the direct dial during COVID-19 where the evidence base is changing and policy solutions are not clear-cut. As Dr. Mijumbi noted, “decision-makers called on the ‘credit’ in the bank” as an analogy to drawing on established trust and relationships with a handful of researchers. The amount of ‘credit in the bank’ therefore determined:
a) if, and to what extent, researchers are playing a role in providing evidence for COVID-19 decision-making
b) how many experts the government has the ability and willingness to draw on
c) to what extent government considers global and local evidence as it deliberates it COVID-19 policies.
Additionally, supporting the COVID-19 response is having various effects on African researchers, including:
- Paring back on research, teaching and writing because their policy and practice work is taking disproportionate amounts of their time.
- Frustration with the EIDM process, especially when their recommendations are not used.
- No time to write funding proposals, even though there has been a boon of funding for COVID-19.
- Burnout that compromises their personal lives.
Research team leaders have seen their work double. All COVID-19 questions that come in from policymakers are urgent, but everyone is working in difficult circumstances: working from home, some with young families, overburdened internet bandwidth, electricity shortages etc. Since researchers are working from anywhere all the time, teams need leaders to help strike balance and manage the flow of work.
And for those with policymaking responsibilities, such as Prof. Samba, they are also constantly balancing the available COVID-19 evidence with other public health concerns and with realistic policy options. Facing researcher colleagues when decisions do not go their way is not an easy position to be in.
While none of these challenges are unique to African researchers, it bears repeating that in regions with a smaller group of EIDM-savvy researchers to draw from, the pressure on them is greater.
COVID-19 has resulted in an unprecedented wave of production of, and demand for, evidence for decision-making. This has created an upsurge of interest as well as skepticism about the quality of research, the contextual relevance of policies, and the changing landscape that bridges evidence to decision-making. While this has resulted in stronger relations between the research and decision-making communities in some contexts, it has also highlighted the glaring gap between these communities in others. Furthermore, it has resulted in a funding system overhaul that has ‘Covidized research’ (compromised existing research activities, redirected the attention of experts, and perpetuated redundancy and waste in research). The impact on researchers at the nexus of COVID-19 and EIDM – from a professional and personal standpoint – has been overwhelming. We have learned that:
- EIDM – particularly in times of emergencies – requires structures that consider multisectoral and multidisciplinary evidence inputs for locally contextualised informed decision making.
- ‘Credit in the (relationship) bank’ between researchers and decisionmakers is critical in order to respond effectively, efficiently and appropriately in times of emergencies.
- En masse pivots to the ’emergency of the time’ can risk research as well as policies on other parallel critical issues.