HLTH 401 F23 Week 4 - _Lessons from COVID-19

Who am I? • U of Guelph alumna – PhD Population Medicine/International Development Studies • Postdoc – UBC (2021-2022) • Postdoc – UW (2023- ) • Spouse, Mother, Chicken & Alpaca-Hobbyist 3

6 Health Governance Dynamic relationships between 3 categories of stakeholders: • Policy-makers: elected (politicians); non-elected (bureaucrats); legislative & executive branches • Providers: public and private (for and not-for- profit) clinical, paramedical, non-clinical health services providers (practitioners, clinical facilities & hospitals, pharmacies, etc.); unions and professional associations • People: citizens and residents, patients’ associations, CSOs, NGOs, the media (Bigdeli et al., 2020)

9 Global Health Security Index (GHSI), 2019 https://www.ghsindex.org/wp-content/uploads/2019/10/2019-Global-Health-Security-Index.pdf (Cameron et al., 2021, p.36)

12 Case Study Rationale (Cameron et al., 2021; p.148)

15 Reflecting global health inequities Access to Care in COVID-19: Philippines • Ecosystem of actors involved in health care services, outside the formal health care system • Low-resource context; LMICs • Strained health human resources • Community health workers (volunteer, ‘lay’ health workers trained by NGOs) fill gaps, extend health services into communities (Dodd, Brubacher, et al. 2022 – Course reading) • International Care Ministries (ICM) works across the Philippines (Visayas, Mindanao) • Staff ‘pivoted’ into providing COVID -19 humanitarian relief, supporting household-level implementation of public health/social measures • Lived experiences of fear; motivation to care

18 Case Study Rationale (Cameron et al., 2021; p.148)

Conceptual Framework 21

22 Factor Definition and examples of key questions Data, measures, observations Institutional The higher- level formal and informal “rules of the game” – e.g. the legal and regulatory basis’ of authority. Respect for laws and legal processes. Reliance on scientists and experts . How do norms for roles and behaviors of key actors and organizations support or constrain effective public health action? Institutional/political analysis Definitions of I, P, O, and G Political Key political actors, their policy positions, and their roles and functions in relation to civil service and technical actors. How do politicians and political processes support or constrain effective public health action? Institutional/political analysis Organizational The “organigram” for structures whose role is to generate public health knowledge and use it for public health action – structure, lines of authority, complexity and fragmentation , etc. Who is “at the table” for what decisions and implementation actions? What authorities and accountabilities influence them? Organigram and organigraph analyses Governance The processes of decision-making and implementation of actions that enable government to carry out its objectives. How were key decisions reached and action enabled? What role for I/P/O factors driving these processes? Key informant interviews related to selected decision points

23 Background: COVID-19 Trajectory in BC Initial Perceptions of British Columbia’s COVID -19 Response • Broadly considered highly-coordinated and effective • 2 nd province (after Ontario) to report a confirmed case • Faster (than ON, e.g.) to respond with infection prevention & control; support for public health measures (Liu et al., 2020) https://www.cbc.ca/news/canada/british-columbia/bc-ontario-quebec-covid-19-1.5524056

24 Background: COVID-19 Trajectory in BC https://www.youtube.com/ watch?v=nLwHwxc1L8A Dr. Henry’s global experience helps BC’s COVID -19 response [4:57] Dr. Bonnie Henry, Provincial Health Officer: The public ‘face’ of BC’s COVID -19 response

25 Background: COVID-19 Trajectory in BC

26 • State of Public Health Emergency declared: March 17, 2020 • Provincial Health Officer: given legal authority to implement orders under BC’s Public Health Act (2008) • State of Provincial Emergency declared: March 18, 2020 • Minister of Public Safety & Solicitor General Mike Farnsworth declared the Emergency Program Act (1996) Background: COVID-19 Trajectory in BC

• 18 semi-structured interviews with key decision-makers involved in British Columbia’s COVID -19 response (July 2021-January 2022) • Provincial and regional public health officials • Government actors (e.g., Ministry of Health, other divisions) • Civil society actors (e.g., unions, research ‘actors’) • Interviews focused on: a) Decision processes leading up the declaration of British Columbia’s state of emergency b) 1-2 ‘key decision clusters’ or ‘key decision points’ • Focused on decisions/processes from Jan.2020 – July 2021 28 Methods

29 Methods

30 ”Pre - First Wave”: Proactivity, Preparedness Findings “ Narrative” of COVID -19 Trajectory in BC • Procuring/locating resources (e.g., ventilators) • Data-sharing across jurisdictions • Creation of “all of government” pandemic plan • Modelling based on international scenarios • Monitoring, surveillance • “This is what we do all the time” (routine outbreak management) • “Domino effect”, “layers of escalation” (January-March 2020)

31 ”First Wave”: Full-on Crisis Management • Early public health orders • Highly operational • COVID-19 as first priority; other work dropped • Centralizing authority to emergency structures • “Cross government approach” • Involvement of PHO & Premier • ”Organic”, “Just doing the next thing” • “high emotions” • Perceived as well-organized and managed overall 1 (March – June 2020) Findings “ Narrative” of COVID -19 Trajectory in BC

Provincial Regional Local Premier and Cabinet Ministry of Health (MOH) Board Resourcing and Development Office (Ministry of Technology, Innovation, and Citizens Services) Other Ministries Minister of Health Deputy Minister of Health Associate Deputy Minister Health Services Diagnostic & Clinical Services Division Health Services Policy Division Population & Public Health Division Provincial Health Officer Deputy Provincial Health Officer(s) Chief Medical Health Officers Health Authority (RHA) • Each HA may have different roles/services • Each HA appoints their own executives FHA IHA NHA IHA VCH BC Centre for Disease Control Communicable Disease & Prevention Services Health Services Laboratory, diagnostics & blood services Genetics Services Acute & provincial services HealthLink BC Mental Health & Substance use Performance & issues management Primary care access Senior services Healthy living & health promotion Public health services branch & office of Aboriginal health Health protection Emergency management unit B.C Public Health Structure: Organogram Other relevant services Medical Health Officers Public Health Workers/Frontline PHSA Specialized public health agencies (9) Other technical divisions Board of Directors Senior Executive Team Executive Directors Managers FNHA CEO Board of Directors 6 divisions (e.g. Chief Medical Office) Board of Directors Senior Executive Team Structure preceding COVID-19 ORGANIZATION S

Provincial Regional Local Provincial Emergency Coordination Centre (PECC) Provincial Regional Emergency Operations Centres (PREOCs) (6) Local Authority Emergency Operation Centres Premier and Cabinet Central Coordination Group Pandemic Cross- Ministry Policy Group Provincial Health Officer BC Centre for Disease Control Ministry-Deputies Emergency Committee Deputy Ministers Committee on Emergency Management Assistant Deputy Ministers Committee on Emergency Management Emergency Management Unit Health Emergency Coordination Centre (HECC) Health Authority Emergency Operations Centre (EOCs) • Public health services • Pandemic roles PHSA FHA IHA NHA IHA VCH Chief Medical Health Officers Medical Health Officers Health Service Delivery/ Region EOCs Site/Facility/Program Response (EOC or ICP) Other Ministries Leadership Council Ministry of Health (MOH) Minister of Health Deputy Minister of Health Associate Deputy Minister (Health Services) HECC Sub committees Deputy Provincial Health Officer(s) Public Health Workers/Frontline BC Health Emergency Management Response Structure: Organogram Provincial EOCs (Outside BC) Provincial Central Coordination Provincial Regional Coordination Site Support Site *Some previously existing structures that did not change are not reproduced again on this chart (First couple months of pandemic – Feb/Mar 2020 to May/June 2020)

34 ”Between First & Second Waves”: Regroup • Re- opening or “restart” • Perception of “it’s over” • Brief reprieve • Deactivation of some emergency sub- structures • “COVID response back into the framework of government”/establishment of COVID - related structures in the Ministry of Health 1-2 (Summer 2020) PAUSE Findings “ Narrative” of COVID -19 Trajectory in BC

Premier and Cabinet Central Coordination Group Ministry-Deputies Emergency Committee Deputy Ministers Committee on Emergency Management Assistant Deputy Ministers Committee on Emergency Management Other Ministries Pandemic Cross- Ministry Policy Group Ministry of Health (MOH) Minister of Health Deputy Minister of Health Associate Deputy Minister (Health Services) BC Health Emergency Management Response Structure: Organogram Provincial Central Coordination Provincial COVID Response and Emergency Management Division Divisional Operations Logistics Strategy Planning Analysis & Reporting Emergency Management Unit Leadership Council Provincial Health Officer Chief Medical Health Officers Deputy Provincial Health Officer(s) Medical Health Officers Public Health Workers/Frontline Health Authority Emergency Operations Centre (EOCs) • Public health services • Pandemic roles PHSA FHA IHA NHA IHA VCH Provincial Emergency Coordination Centre (PECC) Provincial Regional Emergency Operations Centres (PREOCs) (6) Local Authority Emergency Operation Centres Provincial Regional Coordination Regional Site Support Local Site Health Service Delivery/ Region EOCs Site/Facility/Program Response (EOC or ICP) Provincial EOCs (Outside BC) BC Centre for Disease Control *Some previously existing structures that did not change are not reproduced again on this chart VP Pandemic Response (Latter half of pandemic – July 2020 - )

36 ”Second Wave”: Regular Management under Threat • “system normalization” • “population management” • 50-50 proactive vs. reactive • “Fine - tuning our approach” with data management/modelling, coordination between actors with respect to data • Volume/capacity issues: “we knew exactly what we were doing, but we couldn’t deal with the volume” 2 Following this: “third wave” and subsequently: “we were losing our way” (Dec 2020-July 2021) (Sept-Dec 2020) Findings “ Narrative” of COVID -19 Trajectory in BC

37 INSTITUTIONS (informal ‘rules of the game’) Findings “ Narrative” of COVID -19 Trajectory in BC • Precedence given to the voice of the PHO (Dr. Bonnie Henry) in public communications & leading the policy response • Widespread sense of social solidarity & willingness to sacrifice for the general benefit • Public acceptance of significant restrictions • Later, emphasis on a more ‘balanced approach’: reducing restrictions on individual rights/less government interference “British Columbians were quite amazing. People went far beyond anything we asked them to do.” (IDI2) “single trusted voice” (PHO & MOH) “public health [allowed] to take a lead role in the health system...over politics” (IDI12)

38 POLITICS → Independence of Public Health Findings “ Narrative” of COVID -19 Trajectory in BC “I think maintaining the ability for public health to speak independently and reaffirming that and having the processes in place so that doesn’t get compromised is really, really important. And sometimes I would say that the lack of clear process around decision making created the space for those lines to blur.” (IDI1, BCCDC actor) • High degree of cooperation (1 st wave); increasing partisanship & politicization of pandemic response later • Divergent perspectives on the interface of politicians → public health expertise • Political leaders deferred to ‘science’ • Political leaders waded too far into public health “ Government really sort of abdicated their own responsibility, in our view, to the science . In other words, we felt that government, yes you take the science into consideration, the recommendations from the health authorities and the provincial health office. But you have a bigger mandate that you want to have in mind and that is the health and wellness of people “ (IDI18, union rep)

39 Overarching Perceptions of Governance Findings “ Narrative” of COVID -19 Trajectory in BC “I am really concerned that the piece of process and transparency and accountability and communication around decision making is the pivotal piece that we are, I feel like we’re losing this right on more and more. And COVID was a test.” (IDI_15, Elected official) “What we didn’t have is a rigorous enough policy process whereby the synthesis of that more complex public health advice could come from a body and say, here it is...it just feels at the end of the day, it was all conversation among a handful of people . And I hope it was informed by data, but I can’t tell you that it was. I think it was influenced a lot by numerator data.” (IDI_1, BCCDC actor)

40 Findings • Overall impression that decisions were evidence-based/informed • ”Numerator data” (counts) • Certain decisions were/were not evidence-informed • Lack of clarity/transparency Evidence-Informed Decision- Making in BC’s Response Scientific Evidence  → Policy-Making “[In] a communicable disease crisis like a pandemic, the collateral impact slash damage is important and if you’re going to be a public health institute, you actually have to bring those to the front, not just count cases ” (IDI1_Provincial Health Actor) Perceptions of Evidence Use

41 Findings Interface between research  → government Evidence-Informed Decision- Making in BC’s Response Researchers  → Policy-Makers “I think we’ve got to be realistic about what research in a pandemic situation can realistically contribute within very short timelines. I mean, some of these decisions have to be made very quickly...they were intuitive decisions , I think some of them, rather than necessarily evidence-based decisions .” (IDI14_Research Actor) • “Research - friendly” government • “We can do that [ourselves] mentality” • Slow uptake of research • Varying perspectives on the relationship between ‘government’ and public health expertise • “respect and acknowledgement” • “trust of people who understood the problem”

42 Findings Challenges in applying evidence → policy decisions Evidence-Informed Decision- Making in BC’s Response “I think pandemics need strong leadership and I think pandemic research response needed probably stronger leadership than it had. And I think that’s to do with [how] no one really knew who was in charge because no one really was given the role of being truly in charge of the research response ” (IDI14_Research Actor) • Quality/breadth/availability of data (“information shortage”) • AND information abundance/challenges with synthesizing • Debating evidence; digested by the political process, then decisions made • Existing fragmentation in the research ‘enterprise’: need for coordination, collaboration, streamlining (NCCMT, 2023)

43 Findings & Recommendations “The success of BC was twofold. I think, first of all, being that we had public health leadership and a very strong public health act that allowed that to take action in the province to control the pandemic. But I see the second reason was that our government took a coordinated response to support government, to recognize that they b ecame a part of our public health system to support decisions that would then also control the pandemic.” (IDI_9, Ministry of Health)

44 Findings & Recommendations Lessons Learned • Coordinated/centralized leadership in research response • Need for clear mechanisms to apply evidence to decision-making • High level of political cooperation pre- pandemic → lack of ‘politicization’ • Streamlined emergency structures facilitated efficient governance • Balance with important debate/’digestion’ in the political process to consider broader societal implications

45 COVID- 19: “A pandemic of inequality” • Collaboration between health systems at “local, state, and national level[s]” and “ underserved populations ” • Identify and address gaps & barriers in accessing health care services (Etienne 2022, Pan American Health Organization) • A need to address structural vulnerabilities: • Disparities in social determinants of health • Social exclusion and marginalization • Investment in vaccine equity • Investment in health system resources (Sierra et al. 2023) (Etienne 2022) (1) What do we mean by “health” and “health inequality” and ”health equity”? (2) What are the structures and policies we put in place to support or promote health, and how effective are they? (3) Who has the power to shape structures and policies, and whose interests do those structures and policies serve ? (McGrail et al. 2022)

Want to chat about grad school, research, career ideas/hopes, etc.? Feel free to connect! ljbrubacher@uwaterloo.ca LHN 2714 Post-Doctoral Fellow, School of Public Health Sciences With Dr. Dodd 46 Thank you! Questions?

• Balmford B, Annan JD, Hargreaves JC, Altoe M, Bateman IJ. Cross-Country Comparisons of Covid-19: Policy, Politics and the Price of Life. Environ Resource Econ 2020; 76: 525 – 551. https://doi.org/10.1007/s10640-020-00466-5 • Berman P, Cameron MA, Gaurav S, Gotsadze G, Hasan MZ, Jenei K, et al. (2023) Improving the response to future pandemics requires an improved understanding of the role played by institutions, politics, organization, and governance. PLOS Glob Public Health 3(1): e0001501. https:// doi.org /10.1371/journal. pgph.0001501 • Berman P, Keidar S, Zahid M, Hasan MZ, Patrick DM. Same disease, similar measures, varied outcomes: research to improve understanding of why results in curbing COVID-19 has been so different across jurisdictions around the world? Univ Br Columbia Med J. 2021;13(1):7 – 9. • Bigdeli M, Rouffy B, Lane BD The Bellagio Group, et al. Health systems governance: the missing links. BMJ Global Health 2020;5:e002533. • Brubacher, L.J., Hasan, M.Z., Sriram, V., Keidar, S., Wu, A., Cheng, M., Lovato, C.Y., Berman, P. (2022). Investigating the influence of institutions, politics, organizations, and governance on the COVID-19 response in British Columbia, Canada: A jurisdictional case study protocol. Health Research Policy and Systems, 20(74), 1-10. https://doi.org/10.1186/s12961-022-00868-5 • Cameron EE, Nuzzo JB, Bell JA, Nalabandian M, O’Brien J, League A, et al. Global Health Security Index: Building Collective Action and Accountability. Nuclear Threat Initiative and Johns Hopkins Centre for Health Security. 2019. Available from: https://www.ghsindex.org/wp- content/uploads/2019/10/2019-Global-Health- Security-Index.pdf • Chanturidze T, Obermann K. Governance in Health - The Need for Exchange and Evidence Comment on "Governance, Government, and the Search for New Provider Models". Int J Health Policy Manag. 2016 Aug 1;5(8):507-510. https://doi.org/10.15171/ijhpm.2016.60 • Dwyer J, Eagar K. Options for reform of Commonwealth and State governance responsibilities for the Australian health system. Commissioned paper for the National Health and Hospitals Reform Commission. Canberra; 2008. • Etienne, C.F. COVID-19 has revealed a pandemic of inequality. Nat Med 28, 17 (2022). https://doi.org/10.1038/s41591-021-01596-z • Haldane, V., De Foo, C., Abdalla, S. M., Jung, A.-S., Tan, M., Wu, S., . . . Singh, S. (2021). Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries. Nature Medicine, 27(6), 964-980. https://doi.org/10.1038/s41591-021-01381-y • McGrail, K., Morgan, J., Siddiqi, A. Looking back and moving forward: Addressing health inequities after COVID-19. (2022). The Lancet Regional Health Americas. 9:100232. https://doi.org/10.1016/j.lana.2022.100232 • Michael Liu, Colleen J. Maxwell, Pat Armstrong, Michael Schwandt, Andrea Moser, Margaret J. McGregor, Susan E. Bronskill, Irfan A. Dhalla. COVID-19 in long- term care homes in Ontario and British Columbia. CMAJ Nov 2020, 192 (47) E1540-E1546; DOI: 10.1503/cmaj.201860 • National Collaborating Centre for Methods and Tools. Evidence-Informed Decision Making in public Health: What is Evidence-Informed Decision Making in Public Health? (2023). Retrieved March 9, 2023 from: https://www.nccmt.ca/tools/eiph 47 References

• Sierra M, Franco-Paredes C, Agudelo Higuita NI. Health inequities in the global response to the COVID-19 pandemic. Ther Adv Infect Dis. 2023 Apr 10. https://doi.org/10.1177/20499361231162726 • Stowell D, Garfield R How can we strengthen the Joint External Evaluation? BMJ Global Health 2021; 6: e004545. https://doi.org/10.1136/bmjgh-2020-004545 48 References

49 Key Decision Points Declaration of Emergency PPE Guidelines Reducing restrictions (Summer 2020) Ability to enforce by-laws (Late Aug) School Reopening (Sept 2020) Business Safety Plan Requirement Escalating restrictions (Nov/Dec 2020) Vaccination Masking in schools Spring 2020 Summer 2020 Fall 2020 Findings “ Narrative” of COVID -19 Trajectory in BC

0 20 40 60 80 100 120 140 0 1000 2000 3000 4000 5000 6000 7000 8000 Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 Week 12 Week 13 Week 14 Week 15 Week 16 Week 17 Week 18 Week 19 Week 20 Week 21 Week 22 Week 23 Week 24 Week 25 Week 26 Week 27 Week 28 Week 29 Week 30 Week 31 Week 32 Week 33 Week 34 Week 35 Week 36 Week 37 Week 38 Week 39 Week 40 Week 41 Week 42 Week 43 Week 44 Week 45 Week 46 Week 47 Week 48 Week 49 Week 50 Week 51 Week 52 Week 53 Week 54 Week 55 Week 56 Week 57 Week 58 Week 59 Week 60 Week 61 Week 62 Week 63 Week 64 Week 65 Week 66 Week 67 Week 68 Week 69 Week 70 Week 71 Week 72 Week 73 Week 74 Week 75 Week 76 Week 77 Week 78 Week 79 Week 80 Week 81 Week 82 Week 83 Week 84 Week 85 Week 86 Week 87 DEATHS CASES Weeks starting from 1 st March 2020 to 31 st October 2021 Cases Deaths Phase 2 Phase 3 Step 1 Step 2 Step 3 A. 16 March - 8 April 2020: Closures, restrictions on gatherings Focal Point : Public health emergency/provincial state of emergency declarations on 17/18 March, respectively B. 23 March - 11 April 2020: First round of financial support to organizations, individuals Focal Point : Announcement of $5 billion ‘Action Plan’, 23 March C. 7 May - 30 June 2020: First summer restart Focal Point : Re- opening of personal establishments and entry into “phase 2” out of three, 19 May D. 21 September – 24 October 2020: Provincial Election Focal Point : N/A E. 26 October – 24 November 2020: Renewed gathering restrictions, mask order; enforcement penalties strengthened Focal Point : Province-wide travel restrictions enacted, 20 November Phase 1 F. 1 December – 22 December 2020: Second round of financial aid to government organizations, civil society groups Focal Point : Throne speech, 7 December G. 29 March – 30 April 2021: Third round of heightened restrictions: “Circuit Breaker”, travel restrictions Focal Point : Circuit breaker announcement, 29 March H. 25 May – 5 July 2021: Second summer restart Focal Point : Entry into ‘Step 2’, 14 June I. 12 August – 5 October 2021: Restrictions return amidst fourth wave; usage of vaccine- related orders Focal Point : Enforcement of vaccine card begins, 13 September BC’s Restart Plan Summer 2020 (Phase 1, 2 & 3) BC’s Restart Plan Summer 2021 (Step 1, 2 & 3) Figure created by: Shivangi Khanna