Intersectoral collaboration in the COVID-19 response in Latin America and the Caribbean

Abstract

World Health Organization (WHO) / Pan American Health Organization (PAHO) encouraged the utilization of whole-of-society and whole-of-government strategic approaches to increase countries’ resilience towards mitigating the impact of the COVID-19 pandemic. Strategies included the implementation of multi-sectoral, multi-partner and multi-stakeholder planning, coordination, consultation, and action. We reviewed the experiences of three Latin American and Caribbean countries, related to the implementation of collaborative strategies in tackling COVID-19, specifically the nature of the collaboration, the dynamics and the stakeholders involved.

A systematic literature review identified relevant publications and content analysis was conducted to determine the collaborative strategies. Colombia, Costa Rica, and Trinidad and Tobago were selected as case studies since they were from different LAC subregions and because of the accessibility of relevant literature.

In the three countries, the pandemic response was coordinated by a national executive committee, led by the Ministry of Health. Intersectoral collaboration was evident in each, with the key stakeholders being public sector agencies, the private/corporate sector, private/non-profit, academic institutions, and international agencies. It was used primarily to facilitate data-driven, evidenced-informed decision-making and guidelines; to expand clinical care capacity and strengthen the national medical response; and to provide support for the most vulnerable populations.

While the institutionalization of intersectoral collaboration can be recommended for the health sector beyond the pandemic, research is needed to evaluate the impact of specific collaborative strategies as well as barriers and facilitators.

Introduction

Over the last two decades, several international declarations and frameworks have emphasized the importance of strengthening the preparedness of health systems to respond to disasters and health crises or emergencies [1,2,3,4,5]. The consistent underpinning message is that an underprepared health system cannot cope with sudden health service demands, leading to preventable human suffering, loss of life, and economic losses. Each of the six World Health Organization (WHO) health system building blocks (service delivery, health workforce, health information systems, medical products/vaccines/technology, financing, and leadership/governance) includes emergency preparedness and management functions that could contribute to the resilience of the system. This resilience includes the ability of the system to resist, absorb, accommodate, and recover from the effects of a crisis, including the preservation and restoration of essential health services. The COVID-19 pandemic has been an acid test of the readiness of health systems across the globe to attend to emergencies that we had not experienced in over a century.

Latin America and the Caribbean (LAC) countries responded to the pandemic using guidelines from Pan American Health Organization (PAHO) and WHO [6,7,8]. Implementation of recommended public health measures varied within and across countries, and from wave to wave [6, 7, 9]. These strategies included case identification and isolation; contact tracing and quarantine; physical distancing; and hygienic practices. These were also accompanied by drastic labour, educational, and transportation containment measures.

Systems thinking was proposed as the most appropriate approach for policymakers to respond to COVID-19 and its consequences [10, 11]. This has long been recognized as key to strengthening health systems and tackling complex health and social issues and challenges [12]. The ‘whole system approach’ is defined as “a dynamic way of working, bringing stakeholders, including communities, together to develop a shared understanding of the challenge and integrate action to bring about sustainable, long-term systems change” [13]. It involves applying systems thinking methods and practice to understand complex issues and identify collective actions. WHO described this approach as including whole-of-government, whole-of-society, Health in All Policies, and other multi-sectoral and intersectoral actions that transcend traditional sectoral boundaries and build accountability across sectors [14].

Consistent with this, WHO developed its COVID-19 Strategic Preparedness and Response Plan (SPRP), comprising nine technical and operational pillars [15]. The first pillar is Coordination, Planning, Financing, and Monitoring. It proposed that national public health emergency management mechanisms should be activated with the engagement of relevant Ministries to provide coordinated management of COVID‑19 preparedness and response. This pillar endorsed the need for a multi-sectoral, whole-of-government coordination mechanism and knowledge platform that brings together critical people and information to guide, monitor, and review national responses.

The SPRP’s accompanying operational plan provided practical guidance for whole-of-government and whole‑of‑society strategic action that could be adapted [16]. Notably, actions included the requirement to “activate multi-sectoral, multi-partner coordination mechanisms”; and “Engage all relevant national authorities, key partners and stakeholders to develop a country-specific operational plan…” [16]. PAHO’s Framework for the Response of Integrated Health Service Delivery Networks also supported intersectoral approaches in the COVID-19 response [17].

We identified and analysed LAC countries’ experiences in the use of collaborative strategies in their COVID-19 response, as recommended in the SRP. The latter was used as the conceptual framework for the paper.

Methods

A systematic literature review was conducted to identify collaborative strategies adopted by LAC countries in response to COVID-19, published between January 2020 and May 2022. This included a systematic examination of PubMed and Health Systems Evidence databases for publications, as well as a scoping search using Google Scholar and Google search engines to identify grey literature.

Keywords included “intersectoral collaboration” / “multi-sectoral collaboration”; “Latin America and the Caribbean” / “LAC”; “COVID-19” / “SARS-COV-2” / “coronavirus” / “pandemic”; “health services”; “governance” / “health systems governance”; and “leadership”. The inclusion criteria were studies and reports conducted in or focused on LAC countries and published in English or Spanish.

Subsequently, three countries i.e., Colombia, Costa Rica, and Trinidad and Tobago, were selected as case studies. This was based on representation of the principal LAC subregions (South America, Central America, and The Caribbean, respectively) and accessibility of relevant literature.

The initial search strategy yielded over 500 results from database searches and more than 300,000 results from search engine scoping. Most articles were excluded for not meeting the inclusion criteria or not being related to the three selected countries. Notably, 45 articles met the selection criteria (Colombia: 16; Costa Rica: 12; Trinidad and Tobago: 17). Of these, 24 informed the three case studies.

Content analysis of these reports was conducted; that is, we reviewed various aspects of the implementation of intersectoral collaboration in the three countries. The following definition of Intersectoral Collaboration for Health was used: “a recognized relationship between a part or parts of the health sector with a part or parts of another sector, which has been formed to take action on an issue to achieve health outcomes in a way that is more effective, efficient or sustainable than could be achieved by the health sector acting alone” [18]. It was assessed in terms of the purpose of the collaboration (Nature of Collaboration), how they collaborated (Collaboration Dynamics), and the stakeholders who were formally engaged within each sector (Key Stakeholders).

Results

The nature and the dynamics of collaboration as well as the stakeholders who were engaged in the national responses to the COVID-19 pandemic are presented in Table 1. In all three countries, there was evidence of intersectoral collaboration in their national responses to the pandemic. In each country, the Ministry of Health had the overall responsibility for their health sector, including developing and overseeing the implementation of policies [19]. The countries utilized a national coordinating or executive committee, led by the Health Ministry. The latter engaged the following key stakeholders at local/regional and national levels: other public sector actors, private/corporate sector, private/non-profit, academic institutions, and international agencies led by PAHO/WHO. Intersectoral collaboration was used primarily to facilitate data-driven, evidenced-informed decision-making and guidelines; to expand clinical care capacity and strengthen the national medical response; and to provide support for the most vulnerable populations (Table 1).

Table 1 Nature and dynamics and key stakeholders involved in intersectoral collaboration to guide the COVID-19 response in Colombia, Costa Rica, and Trinidad and Tobago

The collaborative dynamics comprised strong and broad interrelationships among the various sectors. These collaborations included diverse strategies, platforms, and mechanisms to promote intersectoral collaboration, facilitate inter-institutional consensus, and support regional and local authorities in decision-making. For example, the participation of academia in committees included providing evidence and consulting for policymaking, inter alia [20, 38]. This dynamic facilitated the conduct of research, and the manufacture of medical supplies through research development and partnerships with industry [20, 34, 41]. Other key actors were involved in production chains and logistic optimization services, lending their networks and expertise to produce COVID-19-related supplies [20]; and strengthening national networks of laboratories to facilitate timely diagnosis/tracking of positive cases [20, 34]. These collaborations also expanded clinical care capacity through donations of medical supplies and funding-related activities [19, 20, 22, 24]. Collaborative efforts also focused on providing support and relief for the most vulnerable populations, such as through financing activities, ensuring food security, and enhancing information and communication technology (ICT) services to address the socioeconomic impacts of the pandemic [21,22,23,24, 26, 32, 33].

Discussion

The three case studies demonstrated the value of intersectoral collaborative action in supporting countries’ COVID-19 responses. These examples can be used by country officials to institutionalize intersectoral collaboration as a strategy to facilitate transparent health decision-making, especially in addressing equity in health and access to services. These lessons are timely as countries prepare for the next public health emergency.

The scope of this report was limited by the paucity of publications in which the collaborative mechanisms in LAC countries’ responses to the COVID-19 pandemic were documented. Initially, the intention was to examine integrative governance and Health in All Policies in LAC countries’ response to the pandemic, in addition to intersectoral collaboration. However, no relevant reports were identified. It should also be noted that the reports that were identified and analysed for intersectoral collaboration did not refer to the SPRP and did not always provide the desired level of pertinent details to fully understand the countries’ collaborative actions.

Even so, we believe that the WHO’s SPRP and its complementary operational plan were appropriate for understanding the collaborative processes in the countries. Future reports should also consider incorporating frameworks from non-health disciplines to obtain a more comprehensive view of the structure and challenges faced in implementing intersectoral collaborative action to address health emergencies. This is important considering the complexity of the dynamics associated with health emergencies, which comprise economic, social, educational, and public health dimensions.

We recommend that multi-country, multi-disciplinary quantitative and qualitative studies be conducted to interrogate collaborative mechanisms in LAC. For instance, key informant interviews can provide greater depth on the collaborative response to the pandemic. Studies should address the presence as well as the facilitators and barriers of intersectoral collaboration, in addition to integrative governance and Health in All Policies in countries’ responses to the pandemic. These studies would identify more specific lessons for future health emergencies. Additionally, while intersectoral collaboration was expected to benefit indicators such as mortality and morbidity, these were not assessed in the present study but should be examined in future research. Finally, cross-country learning exchanges are recommended to identify and promote the adoption or adaptation of promising practices as part of the ongoing preparedness efforts for future health emergencies.

Conclusion

There was evidence of dynamic intersectoral collaboration in the three countries’ COVID-19 response led by the Ministry of Health and including other government agencies, private sector, non-profit organizations, academia, and international agencies. The collaborations focused on provision of evidence to guide decision making; increasing the supply of goods, equipment and services for clinical care; and providing support for the most vulnerable. Research is needed to evaluate the impact of specific collaborative strategies and processes on health outcomes as well as to determine whether intersectoral collaboration for health continued after the pandemic.