Recovery, Renewal, Resilience

Throughout the pandemic, many health systems across the world have come within days of being overwhelmed with COVID-19 patients, and others have been unable to prevent their systems from being overwhelmed. Pakistan have adopted “health stewardship” as an approach to ensure public health is a “joint function of national and provincial governments, where service delivery relies on mixed health systems”. The response in Singh district, which has the highest rate of COVID-19 cases in Pakistan, was underpinned by public-private partnerships with local government. This provides insights into how public-private engagement can be accelerated during the crisis and how “existing policy windows can be used for longer-term planning for pandemics and Universal Health Coverage”. Consider that:

• Stewarding partnerships enabled rapid acceleration of testing through private laboratories, supported surge capacity to be met in local private hospitals and increased “critical care training of public sector hospitals” through partnerships with private hospitals
• “Health stewardship” can enable advisory relationships with the private sector to create a joint operational response and strategic communications during crisis
• Procurement (e.g. of PPE) and supply chain management can be enhanced through “digitalised data-sharing of cases and hospital capacity across private and public providers”
• Stewardship relationships may be transactional (e.g. limited to purchasing arrangements) but can also include “wide-ranging formal agreements for co-production”, providing an opportunity to reform public and private health partnerships
• Devolved operations have proven to offer a flexible and effective response where there is rapid “data sharing for national-provincial coordination, and well-informed local governments who can mobilize inclusive and co-produced responses”

TMB Issue 38 discussed the importance of community involvement in tackling disease outbreaks and presented the recommendations set out by the Independent Panel for Pandemic Preparedness and Response. This briefing offers examples of good practice in community participation during the COVID-19 pandemic. Consider:

• Tanzania: local government co-produced infection control measures with business leaders based in markets to integrate leaders’ understanding & knowledge of the challenges of implementing such measures
• Nigeria: the “community informer model” was employed by local authorities for COVID “surveillance, tracing and monitoring” – community informers are key trusted individuals in a community (e.g. faith leaders)
• Pakistan: community volunteers “set up quarantine wards, manufactured and provided free protective suits for medics”, and distributed food to vulnerable people
• India: Community volunteers came together to investigate and identify unknown (“hidden”) COVID-19 fatalities. The volunteer group comprised of expert physicians and data analysts who developed comparisons of official health data and other reports. This encouraged a review of the national death audit process and resulted in improvements in the process so that COVID-19 deaths were accurate and transparent
• USA: Volunteers built a public “Testing Site Locator” app which visualized the geographical location of testing centres to support collection of testing centre-related information and dissemination at the national level. This supported people to locate the nearest available testing centres and also the “health system to plan and distribute centres more effectively”

The pandemic, and previous disasters, have evidenced that communities play a crucial role when preparing for, responding to and recovering from, crisis. Communities and civil societies should be “partners early on in the design, planning, implementation, and assessment of preparedness and response efforts on all levels”, particularly at the local level. We have covered community participation and co-production with communities in various briefings, see TMB Issue 38; Issue 34; Issue 33.

A current research project, by the Overseas Development Institute, is examining social protection (SP) measures employed during the pandemic in LMICs. The project is producing a series of working papers. One paper examines the inclusion of refugees in government-led SP and the “alignment and integration of cash assistance to refugees and government social protection”. The paper evaluates the effectiveness of social protection responses across four countries in terms of: “Timeliness; coverage adequacy; and level adequacy (value of benefit)”. It also offers the emerging lessons from the study and initial policy recommendations. Consider:

Lessons on the drivers of effective government social protection response

• The maturity of SP systems and pre-existing local and state capacities directly impacted how effectively SP programmes met the needs of refugees during COVID
• Targeting criteria that evaluates eligibility based on risk of vulnerability could be more effective, timely and suitable during a crisis rather than traditional criteria such as length of residency or status
• Benefit levels of government systems are unlikely to be sufficient for refugees’ needs, as these are typically higher than those of nationals and require very careful consideration. The main challenge identified when setting benefit levels which include refugees during the pandemic is that governments are “faced with two competing objectives: (1) preventing social tension and unfairness between population groups” (by varying benefit levels between refugees and nationals); and (2) “ensuring that everyone can meet their basic needs”

Policy recommendations for protecting refugees during a crisis

• Conduct a national socio-economic survey, to include data on refugees’ needs, to develop an overview of the needs of the population across the country. This can enable more effective social protection programme design that effectively meets the needs of everyone
• A review of registration processes can highlight barriers to access for refugees (e.g. in terms of the documents required to register for programmes). Where this is not possible, governments can “draw on international/national/local humanitarian actors’ databases of refugee populations” to swiftly target them with support during crisis
• Hosting governments could consider “integrating refugees into social insurance” (e.g. those with work permits) which may reduce political or public opposition as those receiving benefits will be contributing to national insurance
• Careful consideration of benefit levels and trade-offs between “politically greater acceptability but possibly lower effectiveness” in terms of meeting refugees needs is essential

Low- and middle-income countries (LMICs)

There has recently been a new spotlight shone on the impact that communities have had on their local response. A key message from the UK’s Integrated Review was the need to build whole-of-society resilience through enhancing capabilities in local resilience (see a recent TMB case study). TMB has often highlighted the renewal of community resilience through building a Local Resilience Capability (TMB Issue 30, as well as Briefing A in this current issue). Communities are being seen in a new light in local resilience.

This has been further identified in a paper by the Independent Panel for Pandemic Preparedness and Response, titled ‘Centering communities in pandemic preparedness and response’. This paper emphasizes the importance of community involvement in tackling disease outbreaks and advises of the need to:

• Establish partnerships to work with communities to design, plan, implement and monitor local and national pandemic preparedness and response, for example:
  • In Sur, Oman, the city government developed an intervention of response in partnership with civil society (e.g. community sports clubs, the Omani Women Association, youth groups and voluntary organisations). These groups supported activities to “arrange, maintain, and supervise” pandemic response activities
• Improve community engagement through “clear structures and sustained funding”, recognising that continuous effort is needed (not just a one-off effort during crisis). This can help to develop trust between communities and official service providers
• Recognise that risk communication is key to community engagement, and one part of local resilience capabilities: two-way, bi-directional and co-produced communications are essential to understand needs, communicate responsibilities, and gain feedback (see TMB 37 ‘Risk communications as part of the Local Resilience Capability’)
• Community resilience requires a “sustainable framework for community empowerment and recovery”, including:
  • “Invest in civic mindedness” to establish a culture of social connectedness and empower communities to take responsibility through co-production to understand risk preparedness, response and recovery
  • Establish partnerships between governments and community-based groups/voluntary organisations/businesses to integrate communities into the planning and leadership of interventions that enhance their local resilience
  • “Invest in social and economic wellbeing, and in physical and psychological health” to ensure access to health services

Many local/town centre businesses will be micro- and small-medium enterprises (MSMEs) that have been severely impacted by the pandemic and lack internal resources to support recovery. In Pakistan, MSMEs contribute 40% to GDP and are critical to the economy, as they are in many other countries. In developing support strategies for local businesses and MSMEs, it is important to recognise that the pandemic has changed working practices and locations, and how we shop and entertain ourselves. Small businesses may not have the resources to access the type of data that can inform them on these potential changes to consumer habits, which in turn could impact trade levels as restrictions ease and these businesses re-open. Local governments can support them by facilitating access to this information. Consider:

• Build capacity of local government staff to undertake local economic assessments and develop small town regeneration and renewal plans (e.g. train staff to conduct economic impact assessments to identify businesses that may struggle post-lockdown and strategies that will support local economy recovery)
• Engage with local businesses, MSMEs and organisations that represent them (e.g.FSB UK) to draw on their perspectives and expertise when developing recovery and renewal plans
• Identify what has gone well in previous phases of re-opening, what could be improved and the support needs of these businesses (e.g. management of queues/health and safety measures to mitigate and contain the virus)
• Provide support grants to MSMEs for business regeneration or local marketing strategies to promote local businesses
• Conduct local and regional consumer habit surveys, in partnership with neighbouring local authorities, to identify the expectations of local consumers, and their potentially changed habits
• Communicate findings rapidly to local businesses so that they are informed and can prepare/pivot their businesses appropriately
• Develop an evidence-based local economic strategy that recognises changed consumer habits and demands, in partnership with local businesses
• Provide guidance to local businesses on how to adapt and where new business opportunities may lie (renewal)
• Signpost local businesses, particularly MSMEs, to training for digital skills and to advice on finance/investment in new technologies
• Develop a mechanism whereby local government can share lessons and knowledge between each other easily to learn from each other (e.g. collaborative 'light touch' impact assessments as described in Briefing A)

The SDGs, represent the world's agreed economic, social, and environmental targets for 2030, and can act as a common scorecard to ensure there are objective standards for assessing progress. Localising the ambition of the SDGs to develop local economic development strategies can help integrate social and environmental standards within local economic agendas, reduce disparities between regions, generate local business opportunities and jobs, and aim to include all marginalized communities. Consider how the SDG framework can support inclusive and diversified economic growth:

• Integrate SDG targets into on-going budget reviews process, thereby improving resource allocation and performance evaluation
• Examine the link between ongoing public policies, the SDG targets and budget expenditures
• Analyse the official indicators related to budget-planning instruments
• Partner with the private sector to launch impact investment initiatives that address the SDGs, recovery and renewal from COVID-19 and sustainable economic renewal

In Pakistan, a National Immunization Support Project (NISP) supported by the World Bank has developed wider strategic collaborations to transform immunization by increasing vaccination coverage and strengthening existing systems and mechanisms. At the heart of NISP is a pooled procurement mechanism and governance structures which successfully sourced vaccines for Provinces and provided an uninterrupted supply for the past 4 years in an efficient and collaborative manner. When COVID-19 hit, NISP: (1) had a series of trusted partners, so repurposed its trusted procurement mechanism e.g. to procure PPE for health care workers; and, (2) was a trusted partner itself, so provided its own expertise to other partners beyond its usual remit e.g. to provide financial management governance to oversee funds. Inspired by (1), consider how your organisation can repurpose trusted partnerships and identify:

• Major issues that are troublesome due to limited effective partnerships available to support
• Where trusted strategic partnerships are already established and proven to be working well
• How strategic partners can expand their collaboration to address the troublesome issues
• The blockers, how to overcome them, and to expand the partnership to support response

Inspired by (2), consider how your organisation is the trusted partner that can help others and identify:

• What general expertise your organisation has and is able to provide in support to partners
• How your organisation can repurpose key skills and capabilities to go beyond its usual remit to offer support as a trusted partner
• How your organisation can provide its normal services whilst providing support to response
• The blockers, and how to overcome them, to provide your capabilities to others' response