Governance of the Covid-19 response: a call for more inclusive and transparent decision-making

Abstract

Summary box Not all countries make their Covid-19 task force membership list public—the available information varies by country. There is currently a predominance of politicians, virologists and epidemiologists in the Covid-19 response at the country level. Experts on non-Covid-19 health, social and societal consequences of Covid-19 response measures are, for the most part, not included in Covid-19 decision-making bodies. There is little transparency regarding whom decision-making bodies are consulting as their source of advice and information. From the available data on Covid-19 decision-making entities, female representation is particularly paltry. In addition, civil society is hardly involved in national government decision-making nor its response efforts, barring some exceptions. We need to be more inclusive and multidisciplinary: the Covid-19 crisis is not simply a health problem but a societal one—it impacts every single person in society one way or another. Decision makers need to address more systematically the suffering from mental illness exacerbations, domestic violence, child abuse, child development delays, chronic diseases and so on, during lockdown. Introduction As SARS-COV-2 (severe acute respiratory syndrome coronavirus 2) ravages the globe, heads of state are making swift decisions to put large swathes of the world’s population under mass isolation in the race to heed off Covid-19’s lethality, particularly in certain population subgroups. How are these decisions—that affect each and every one of us, some groups disproportionately and regardless of Covid-19 status—made? How far have policy makers and politicians consulted those who have experience and expertise on the secondary effects of lockdowns, social isolation measures and movement restrictions? We attempted to address these questions with a rapid analysis of 24 countries’ Covid-19 task force compositions. The countries were selected to represent a range of geographies and income levels. As far as possible, we focused on governance bodies set up or activated to give scientific, or evidence-based, advice to national decision makers. In some countries, the advisory and decision-making bodies were one and the same, often taking the form of government-only interministerial committees. We excluded committees which were established to focus on a specific area, for example, research related to vaccination; rather, we examined committees whose explicit mandate (based on available information) was to provide advisory guidance on the overall national response. We scanned publicly available documentation from government websites, media articles, and in specific cases, contacted our networks in governments and health ministries for official documentation. We then researched the task force members’ backgrounds and triangulated from different sources to classify them based on their current professional role or area of specialisation. Experts were thus categorised based on the principal reason for their appointment to the task force. For example, a physician with a current public health role would be classified as a public health specialist and not a clinician, the assumption being that their current role is most relevant for the task force. The ‘government’ or ‘Ministry of Health’ category was allocated to career civil servants, that is, posts which are usually filled by generalists rather than specialists. Most other task force members, including public health institute staff, were categorised according to their expertise since the rationale for their task force membership is their specific skill set (mathematical modeller, virologist, etc) rather than their institutional affiliation. At least two coauthors independently categorised the task force members and crosschecked categorisations with each other. How inclusive and transparent is Covid-19 decicion-making? We highlight a number of key issues, some very worrying, made evident by table 1: Table 1 Covid-19 task forces set up to advise national governments Country Name of task force convened or activated for Covid-19 response Composition of task force by member expertise Gender distribution Argentina28 Expert Committee (El comité de expertos) 5 Government officials 2 Ministry of Health officials 6 Infectious disease specialists 1 Epidemiologist 1 Public health specialist 12 M; 3 F Belgium29 30 Scientific Committee Coronavirus (Comité scientifique Coronavirus) 3 Infectious disease specialists 1 Epidemiologist 1 Laboratory specialist 2 M; 3 F Burkina Faso31 Name unknown 1 Ministry of Health official 4 Infectious disease specialists 2 Epidemiologists 3 Public health specialists 2 Other medical specialists 1 Communication specialist 1 Private sector 4 Unknown 14 M; 5 F Chad32 Scientific Committee for Covid-19(Comité Scientifique Covid-19) 1 Ministry of Health official 7 Infectious disease specialists 1 Epidemiologist 1 Laboratory specialist 8 Public health specialists 2 Intensive Care specialists 12 Other medical specialists 1 Pharmacist 1 Nutrition specialist 1 Lawyer 1 Socioanthropologist 1 Historian 33 M; 4 F Chile33 Advisory Board of Ministry of Health for Covid-19(Consejo Asesor del MINSAL por Covid-19) 2 Ministry of Health officials 1 Infectious disease specialist 3 Public health specialists 1 Other medical specialist 3 M; 4 F China34 35 Central Leading Group on Responding to the Novel Coronavirus Disease Outbreak 9 Government officials 8 M; 1 F France36–39 Scientific council Covid-19(Conseil scientifique Covid-19) 4 Infectious disease specialists 1 Epidemiologist 1 Mathematical modelling specialist 1 Intensive Care specialist 1 Other medical specialist 1 Anthropologist 1 Sociologist 8 M; 2 F Analysis, research and expertise committee(Comité analyse, recherche et expertise (CARE)) 6 Infectious disease specialists 1 Mathematical modelling specialist 2 Laboratory specialists 2 Other medical specialists 1 Anthropologist 7 M; 5 F Germany40–42 Interministerial crisis unit(Krisenstab) Government officials from six different ministries Unknown Guinea43 44 Scientific council on pandemic response to coronavirus disease (Covid-19)(Conseil scientifique de riposte contre la pandémie de la maladie à coronavirus (Covid-19)) 2 Infectious disease specialists 1 Epidemiologist 1 Laboratory specialist 3 Public health specialists 3 Pharmacists 3 Other medical specialists 1 Psychologist 1 Economist 2 Socioanthropologist 14 M; 3 F Haiti45 Scientific committee to combat coronavirus(Cellule scientifique pour lutter contre le coronavirus) 1 Ministry of Health official 2 Infectious disease specialists 1 Epidemiologist 1 Laboratory specialist 2 Public health specialists 1 Intensive Care specialist 3 Other medical specialists 1 Mental health specialist 1 Sociologist 1 Civil society 12 M; 2 F Hungary46 Coronaviral Defence Operational Staff(Koronavírus-járvány Elleni Védekezésért Felelős Operatív Törzs) 11 Government officials 3 Ministry of Health officials 1 Infectious disease specialist 14 M; 1 F Italy47–49 Operational Committee on Coronavirus for Civil Protection(Comitato operativo sul Coronavirus alla Protezione Civile) 6 Government officials 1 Ministry of Health official 7 M; 0 F Scientific Technical Committee(Comitato Tecnico Scientifico) 4 Ministry of Health officials 2 Infectious disease specialists 1 Public health specialist 7 M; 0 F Task force tech anti Covid-19 2 Government officials 2 Ministry of Health officials 2 Infectious disease specialists 5 Epidemiologists 1 Mathematician 4 Public health specialists 1 Social scientist 12 Data management specialists 4 Statisticians 1 Physicist 1 Civil engineering expert 1 Digital health expert 1 Chemist 1 Information systems expert 13 Economists 3 Computer science experts 1 Communication technology expert 3 Digital transformation experts 2 Emergency management experts 11 Lawyers 1 Unknown 56 M; 18 F Kenya50 51 National Emergency Response Committee 17 Government officials 4 Ministry of Health officials 15 M; 6 F Mali52 53 Crisis Committee(Le Comité de crise) 2 Governmental officials 2 Ministry of Health officials 1 Infectious disease specialist 2 Laboratory specialists 4 Public health specialists 1 Other medical specialist 12 M; 0 F Scientific and Technical Committee of the National Public Health Institute(Comité Scientifique et Technique de l’Institut National de Santé Publique -INSP) 5 Infectious disease specialists 1 Public health specialist 1 Other medical specialist 1 Agronomist 1 Ecologist 1 Nutritionist 9 M; 1 F Philippines54 Inter-Agency task force 2 Government officials 2 Ministry of Health officials 4 M; 0 F National task force Covid-1919 (National Disaster Risk Reduction and Management Council - NDRRMC) 4 Government officials 4 M; 0 F Portugal55 56 Task force Covid-19 13 Infectious disease specialists 10 Epidemiologists 12 Public health specialists 1 Intensive Care specialist 5 Other medical specialists 1 Chemist 2 Communication specialists 25 Unknown 26 M; 42 F National Public Health Council(Conselho Nacional de Saúde Pública) 2 Government officials 2 Ministry of Health Officials 5 Infectious disease specialists 1 Epidemiologist 2 Public health specialists 1 Other medical specialist 1 Pharmacist 2 Lawyers 1 Private sector 2 CSO 14 M; 6 F Singapore57 Multi-Ministry Taskforce on Wuhan Coronavirus 10 Government officials 1 Ministry of Health official 10 M; 1 F South Korea58 59 Central Disease Control Headquarters (KCDC) Led by Jung Eun-Kyeong (Director) Other members unknown 1 F, unknown Central Disaster and Safety Countermeasures Headquarters Led by the Prime Minister (Chung Sye-kyun) Other members unknown 1 M, unknown Central Incidence Management System for Novel Coronavirus Infection Led by Minister of Health and Welfare (Park Neung-hoo) Other members unknown 1 M, unknown Central Disaster Management Headquarters Led by Ministry of Health and Welfare (Park Neung-hoo) Other members unknown 1 M, unknown Government-wide Support Centre Led by Minister of Public Administration and Security Other members unknown 1 M, unknown Local Disaster and Safety Countermeasures Headquarters (local municipal governments nationwide) Led by the head of the local government Other members unknown Unknown Local quarantine task force (local municipal governments nationwide) Led by the head of the local government Other members unknown Unknown Spain60 Scientific Technical Committee Covid-19(Comité Cientifico Técnico Covid-19 19) 3 Infectious disease specialists 3 Epidemiologists 3 M; 3 F Switzerland61 Science Task Force 6 Infectious disease specialists 2 Epidemiologists 1 Mathematical modelling specialist 1 Laboratory specialist 2 Public health specialists 1 Environmental engineering expert 1 Computer science expert 1 Economist 1 Bioethics expert 12 M; 4 F Thailand62 National committee for controlling the spread of Covid-19 26 Government officials 2 Ministry of Health officials 28 M; 0 F Vietnam63 Committee for Covid-19 Prevention and Control(Tiểu ban giám sát phòng, chống dịch bệnh Covid-19). 5 Government officials 9 Ministry of Health officials 13 M; 1 F United Kingdom64–66 New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG) 9 Infectious diseases specialists 1 Epidemiologists 2 Mathematical modelling specialists 1 Public health specialist 1 Intensive Care specialist 1 Sociologist 1 Psychologist 14 M; 2 F Advisory Committee on Dangerous Pathogens (ACDP) 1 Government official 12 Infectious disease specialists 1 Mathematical modelling specialist 1 Public health specialist 1 Other medical specialist 13 M; 3 F Joint Committee on Vaccination and Immunisation (JCVI) 19 Infectious disease specialists 1 Other medical specialist 1 Lay member (unknown) 12 M; 9 F USA67 68 White House Coronavirus Task Force 19 Government officials 1 Ministry of Health official 3 Infectious disease specialists 21 M; 2 F 1.‘Evidence’ seems to be largely understood to mean research-based evidence, and not necessarily experiential, implementation-based evidence from the field The vast majority of Covid-19 response task force members are from reputed universities and government institutes where rigorous research is conducted in the classical sense, often under clinical trial or laboratory conditions. Information and evidence on the lived experiences and everyday challenges faced by the various groups in society who are (at times, severely) affected by isolation measures seem to be altogether overlooked in the urgency of the current situation. 2. Among researchers, mainly virologists and epidemiologists seem to be consulted, leaving out other health and also non-health experts Most countries acknowledge the need for government to work jointly with the medical (and public health) community in the national Covid-19 response. However, mainly virologists and epidemiologists seem to be consulted, largely leaving out specialists in areas such as mental health, child health, chronic diseases, preventive medicine, gerontology, not to mention experts in non-health spheres. Social isolation measures have enormous secondary effects1 beyond the primary aim of curbing viral spread. These effects go far beyond health (discussed below). But even within the health space, the consequences of not accessing, or inadequately accessing,2 basic essential services for a wide range of non-Covid-19-related conditions3 do not seem to have been sufficiently considered. 3. When the task force is government-only, more non-health sectors seem to be represented, but at the detriment of non-government expertise Still, some countries’ Covid-19 task forces are government-only. In those cases, there at least seems to be a stronger presence of non-health sectors, although to the detriment of non-government expertise. In a number of countries, Covid-19 task forces consist of high-level government cadres only, combining the advisory and decision-making elements into one. Medical and epidemiological expertise seems to come from government health institutions, but it is not always clear who is being consulted beyond government. A multiministry task force at least theoretically brings in concerns from other sectors such as education,4 economy, interior, and so on, potentially raising serious issues in terms of, for example, child development5 (relevant to decisions on school closures, for example),6 loss of livelihoods7 (particularly relevant in low-income countries8 and those with large social inequalities and no social safety net), and further marginalisation of migrants9 and illegal workers (who often have nowhere to isolate to). However, how far those concerns are actually taken into consideration is impossible to discern without more transparency with regard to the content of deliberations and potential consultations with external parties. 4. Civil society and community groups do not seem to be consulted at all In addition to civil society and community groups not being engaged in primary discussions, neither are social workers, child development specialists, human rights lawyers, and many other people whose experiential and vocational expertise are particularly relevant in terms of societal rights, and groups affected by isolation measures. The WHO weekly Covid-19 situation update from 15 April mentions that only 36% of member states reported having a Covid-19 community engagement plan.10 In addition, a majority of the 175 civil society respondents from 56 countries confirmed in a recent rapid survey of the UHC2030 Alliance’s Civil Society Engagement Mechanism that most of their Covid-19 response work was, indeed, independent of the government. Results and methodology of the survey can be found here. Vulnerable groups11 such as the disabled,12 those with serious mental health conditions,13 single mothers,14 people in abusive family relationships15 and the elderly16 bear the burden of the negative consequences of isolation and loneliness, potentially threatening the social fabric of society. Civil society organisations, community groups, social workers, nurse-caregivers and many other groups are at the front lines with this broad cross-section of society clearly affected by the far-reaching effects of mass isolation. Civil society can also raise awareness on existing social inequalities which are usually exacerbated in crisis situations, leaving many to feel that ‘self-isolation is a privilege for the rich’.17–20 If there is one thing that we should learn from another virus-based crisis (HIV), it is that the population, communities and civil society are an integral part of the crisis solution.21 5. Women are a minority in Covid-19 task forces, and are not represented at all in some The Women in Global Health movement has already lamented the abysmally low proportion of women represented in global Covid-19 response efforts.22 Besides some notable exceptions, the same low percentages of female experts are seen across the national task forces we rapidly reviewed, with some task forces even being all male. Women’s perspectives and expertise clearly seem to be heard less often than male colleagues, even while the majority of front-line health staff fighting the crisis is female.23 6. More transparency is needed on who is taking decisions and how We took great pains to scan a broad variety of websites, newspapers and government documents in several languages within a short amount of time. Still, information on (1) Who is making far-reaching decisions on an unprecedented global and national crisis? (2) How decision makers are reaching their conclusions (ie, who else are they reaching out to for advice)? (3) Which exact positions advisers had? was not always easy to come by. There are signs that some countries’ governments and/or Covid-19 task forces are indeed consulting with outside parties24 relevant to the secondary consequences of long-term isolation25 but this information is generally not clear and transparent. In addition, transparency on selection criteria for the task forces themselves is needed to better understand the weight given to the different aspects of the outbreak. Conclusion We acknowledge that the information may not be complete, nor completely up to date, given the extremely fast-paced dynamic of the Covid-19 outbreak as well as response measures. We also recognise that Covid-19 task force compositions are not the sole indication of whose voices are included in decision-making. Through the fairly broad range of (mostly) publicly available information analysed, we attempted to understand which groups the task forces were reaching out to within the scope of a rapid analysis. In general, protocols, reports, minutes of task force meetings and lists of externally consulted parties were simply not easily available. Nevertheless, we feel that the broad conclusions we take based on our rapid (but imperfect) analysis still hold based on the information we were able to access. The table above displays the list of countries and their available task force information. Governments must recognise the multidimensional effects and needs of society26 during this Covid-19 crisis and consult more broadly and across disciplines, within health and beyond health, based on a true multisectoral paradigm. More importantly, more transparency is needed regarding who decision-making bodies are listening to as a basis for their decisions. Now more than ever, the voices of those who are at risk of getting left behind need to be heard.27 In the end, we must ensure that we do not do more harm than good with the measures in place to protect our at-risk populations.