key: cord-0288522-mjt4rba6
authors: Boyce, M. R.; Asprilla, M. C.; van Loenen, B.; McClelland, A.; Rojhani, A.
title: How do local-level authorities engage in epidemic and pandemic preparedness activities and coordinate with higher levels of government? Survey results from 33 cities
date: 2022-05-26
journal: nan
DOI: 10.1101/2022.05.25.22275614
sha: 532e25abe75b70ac435e7010344241ed4b066457
doc_id: 288522
cord_uid: mjt4rba6

The COVID-19 pandemic suggests that there are opportunities to improve preparedness for infectious disease outbreaks. While much attention has been given to understanding national-level preparedness, relatively little attention has been given to understanding preparedness at the local-level. We, therefore, aim to describe (1) how local governments were engaged in epidemic preparedness efforts before the COVID-19 pandemic and (2) how they were coordinating with authorities at higher levels of governance before COVID-19. We developed an online survey and distributed it to 50 cities around the world involved in the Partnership for Healthy Cities. The survey included several question formats including free-response, matrices, and multiple-choice questions. RACI matrices, a project management tool that helps explain coordination structures, were used to understand the level of government responsible, accountable, consulted, and informed regarding select preparedness activities. We used descriptive statistics to summarize local-level engagement in epidemic preparedness. Local health authorities from 33 cities completed the survey. Prior to the COVID-19 pandemic, 20 of the cities had completed infectious disease risk assessments, 10 completed all-hazards risk assessments, 11 completed simulation exercises, 10 completed after-action reviews, 19 developed preparedness and response plans, three reported involvement in their countrys Joint External Evaluation of the International Health Regulations, and eight cities reported involvement in the development of their countries National Action Plan for Health Security. RACI matrices revealed various models of epidemic preparedness, with responsibility often shared across levels, and national governments accountable for the most activities, compared to other governance levels. In conclusion, national governments maintain the largest role in epidemic and pandemic preparedness but the role of subnational and local governments is not negligible. Local-level actors engage in a variety of preparedness activities and future efforts should strive to better include these actors in preparedness as a means of bolstering local, national, and global health security.

The actual or potential actions that may be taken by local governments are often influenced by 95 policy, guidance, and financing from higher levels of governance [18, 19] . In many cities, total 96 autonomy from higher levels of government is unlikely, and coordination between these actors 97 is, therefore, an important consideration. This is especially true as inadequate coordination and 98 poor governance can lead to implementation challenges, the inefficient use of limited resources, 99 and greater health consequences [4, 16, 20, 21] . 100 101 These considerations lead to questions about not only how local governments and authorities 102 were engaging in epidemic preparedness before the COVID-19 pandemic, but also the roles they 103 played and how these efforts were coordinated with higher levels of government. The objectives 104 of this descriptive research, then, are to understand the ways in which local-level authorities were 105 engaging in preparedness efforts before the COVID-19 pandemic, as well as how they were 106 coordinating with authorities at higher levels of governance to complete key tasks and 107 preparedness activities. 108 109 Methods. 110 The research described in this article used a survey study design to ask local public health 111 authorities in cities around the world about their city's engagement in pandemic preparedness 112 efforts prior to the COVID-19 pandemic and how select preparedness activities were coordinated 113 with higher levels of government. 114 115 Study Population. This research effort involved public health authorities from cities that were a 116 part of the Partnership for Healthy Cities. The Partnership for Healthy Cities is a city network of 117 70 cities that have committed to preventing noncommunicable diseases and injuries through . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 26, 2022. ; https://doi.org/10.1101/2022.05.25.22275614 doi: medRxiv preprint 118 proven, evidence-based interventions and approaches. In March of 2020, recognizing the 119 urgency of COVID-19 response, the network temporarily expanded its scope to include support 120 for pandemic response. The population involved in this study included 50 cities in the 121 Partnership for Healthy Cities that were purposively selected based on their involvement in a 122 mini-grant program that focused on bolstering the local response to the COVID-19 pandemic.

124 Questionnaire Development and Distribution. We developed a survey questionnaire based on 125 existing pandemic preparedness frameworks and guidance [22, 23] . The survey contained 17 126 questions -relating to participant demographics and preparedness efforts and activities -that 127 included a variety of formats including free-response, matrices, and multiple-choice questions.

128 The survey questionnaire is available for review in the S1 Appendix.

Included in these questions were RACI (i.e., Responsible, Accountable, Consulted, and 130 Informed) matrices [24] . RACI matrices are project management tools that are useful for 131 explaining coordination structures and the hierarchical nature of activities. Multiple levels of 132 government can be responsible, consulted, and informed for a given activity. However, only one 133 level of government can be accountable for a given activity. These queries allowed for survey 134 responses to provide a granular look at how local preparedness activities related to and were 135 coordinated with those of higher levels of government.

For the purposes of this study, we defined responsibility as implementing the work 137 required to complete an activity; accountability was defined as overseeing the correct and 138 thorough completion of an activity; consulted was defined as engaging in two-way 139 communication to provide information necessary for the completion of an activity; and informed 140 was defined as being updated on progress toward or on the results from a given activity (i.e., . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 

. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) 

The activities national authorities were most often responsible for include developing 219 pandemic preparedness and response policy (n=32), financing routine public health activities 220 (n=28), and identifying and mapping resources required for the response to public health 221 emergencies (n=25) (Fig 2) ; the activities subnational authorities were most often responsible for 222 include operationalizing pandemic preparedness and response policy (n=28), developing and 223 maintaining pandemic preparedness and response plans (n=27), and developing mechanisms for 224 coordination between levels of government (n=26); the activities local authorities were most 225 often responsible for include operationalizing pandemic preparedness and response policy 226 (n=28), developing mechanisms for coordination between levels of government (n=25), and 227 developing and maintaining pandemic preparedness and response plans (n=25). Relative to other 228 the other levels of government, national authorities were most frequently reported to be 229 responsible for three of the 11 pandemic preparedness activities (i.e., developing pandemic . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Relative to the other levels of government, national authorities were reported to most 240 often accountable for seven of the 11 pandemic preparedness activities, national and subnational 241 authorities for one of the activities, subnational and local authorities for one of the activities, and 242 local-level authorities for two of the activities (Fig 3) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 26, 2022. ; https://doi.org/10.1101/2022.05.25.22275614 doi: medRxiv preprint 259 levels of government (n=14) (Fig 4) ; subnational authorities were most often engaged in 260 consultation for developing pandemic preparedness and response policy (n=24), operationalizing 261 pandemic preparedness and response policy (n=19), developing and maintaining pandemic 262 preparedness and response plans (n=19), and conducting after-action reviews following public 263 health emergencies or events (n=19); local authorities most often engaged in consultation for 264 developing mechanisms for coordination between levels of government (n=15), developing and 265 maintaining pandemic preparedness and response plans (n=14), and identifying and mapping 266 resources required for the response to public health emergencies (n=13). . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 26, 2022. The results of this work highlight that, according to local governments and public health 299 authorities, before the COVID-19 pandemic, epidemic and pandemic preparedness in cities was 300 largely left to higher levels of government. Of the activities included in our survey, national 301 governments were both responsible for implementing and accountable for overseeing a majority 302 of the activities, when compared to subnational and local governments. Still, the role of local 303 governments was not insignificant, as they were the level of government most often accountable 304 for overseeing and responsible for operationalizing pandemic preparedness and response policy, 305 and for overseeing routine infectious disease surveillance activities and conducting the initial 306 investigation of outbreaks. They were also frequently consulted by higher levels of government 307 as they developed mechanisms for coordination between levels of government, developed and 308 maintained pandemic preparedness and response plans, and identified and mapped resources 309 required for the response to public health emergencies.

. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 

. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) 356 This study and its results suffer from several limitations. First, and most significantly, the results 357 relied on the completion of a survey by one individual. While we attempted to distribute the 358 survey to the local authority who would be most knowledgeable about epidemic and pandemic 359 preparedness in the city, we cannot guarantee that the data captured by responses are completely 360 valid or factual. One person's knowledge regarding all of the preparedness efforts, activities, and 361 arrangements in their city may be limited. For instance, a majority of survey participants had 362 served in their current professional role for one to four years and may not have been aware of 363 preparedness efforts in their city before this time. Future research may wish to more deeply 364 examine preparedness efforts in specific cities or to validate the results of this study by 365 reviewing the legislation, regulations, and other legal frameworks that provide the foundation for 366 public health preparedness and coordination between levels of government. 367 368 Additionally, the specific results from each city are unlikely to hold great amounts of external 369 validity. The governance contexts in which participating cities exist vary widely, and it would be 370 inappropriate to generalize results across contexts without examining the specific authorities of 371 local-level authorities. Indeed, the powers of local governments can differ significantly between 372 cities within the same country, let alone between cities in different countries. It is for this reason 373 that our study provides descriptive statistics to summarize broad trends in urban health security 374 in cities around the world, instead of attempting to overstate our results and risk inappropriately 375 generalizing across contexts. 376 377 In conclusion, the results of this research suggest that, according to local-level authorities, their 378 involvement in epidemic and public health preparedness before the COVID-9 pandemic was . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 26, 2022. ; https://doi.org/10.1101/2022.05.25.22275614 doi: medRxiv preprint . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 26, 2022. ; https://doi.org/10.1101/2022.05.25.22275614 doi: medRxiv preprint

While many had completed risk assessments and developed some form of 380 response plan, fewer had been involved in capacity assessments or tested the functionality of 381 existing capacities through simulation exercises or after-action reviews. Further, while national 382 governments seemingly represent the level of government that is primarily responsible and 383 accountable for preparedness, local governments still maintained much responsibility and a large 384 role in operationalizing policy and implementing activities. Opportunities for improving public

Our thanks to Mariana Espinosa Estrada, Charity Hung, Ramya Kancharla, Sherissa Ng

Rourke of Vital Strategies for their assistance in the 392 distribution of survey and study materials. Thanks also to Rebecca Katz of the Georgetown 393 Center for Global Health Science & Security for her review of early drafts and comments that

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