Decisive leadership is a necessity in the COVID-19 response
Authors: Ahmed Mohammed Obaid Al Saidi, Fowsiya Abikar Nur, Ahmed Salim Al-Mandhari, Maha El Rabbat, Assad Hafeez, Abdinasir Abubakar
Journal: The Lancet (2020)

The COVID-19 pandemic poses one of the greatest threats in recent human history as the virus has spread rapidly worldwide, affecting the lives and livelihoods of billions. As of June 30, 2020, according to WHO, more than 1 million cases of COVID-19 had been confirmed in its Eastern Mediterranean Region (EMR) alone, with considerable differences in the scale and progression of the pandemic in different countries.1WHOWHO coronavirus disease (COVID-19) dashboard.https://covid19.who.int/Date: June 30, 2020Date accessed: June 30, 2020Google Scholar With national governments at the forefront of response and mixed reactions displayed by political and public health leaders, decisive leadership is emerging as a key factor in determining success. Examples of effective responses around the world and in the EMR include rapid response, good coordination, an evidence-based approach that is well communicated, and partnership spirit. Numerous factors have been proposed to account for the variation in the numbers of COVID-19 cases and deaths relative to population. For example, the disparities in health system capacities must be acknowledged, although the pandemic has even overwhelmed some countries with advanced capacities.2Algaissi AA Alharbi NK Hassanain M Hashem AM Preparedness and response to COVID-19 in Saudi Arabia: building on MERS experience.J Infect Public Health. 2020; 13: 834-838Crossref PubMed Scopus (219) Google Scholar Demographics could be important, with the high numbers of cases and deaths in Italy possibly partly due to an elderly population and high prevalence of comorbidities, as well as cultural factors such as high levels of socialisation, which might influence compliance with public health measures.3Boccia S Ricciardi W Ioannidis JPA What other countries can learn from Italy during the COVID-19 pandemic.JAMA Intern Med. 2020; (published online April 7.)https://doi.org/10.1001/jamainternmed.2020.1447Crossref PubMed Scopus (230) Google Scholar Nevertheless, the role of leadership in pandemic response remains undeniable. A recognised characteristic of decisive leadership is rapid response, based on a clear understanding of the threat posed by COVID-19 and that delayed action could lead to worse outcomes. In a study of national responses, there was substantial variation in the rate and speed at which stricter measures were adopted.4Hale T Angrist N Kira B et al.Variation in government responses to COVID-19 (version 6.0).Blavatnik School of Government working paper.https://www.bsg.ox.ac.uk/sites/default/files/2020-05/BSG-WP-2020-032-v6.0.pdfDate: May 25, 2020Date accessed: June 25, 2020Google Scholar Even for similar lockdown measures, earlier implementation was associated with better outcomes.5Gibney E Whose coronavirus strategy worked best? Scientists hunt most effective policies.Nature. 2020; 581: 15-16Crossref PubMed Scopus (103) Google Scholar In Germany and New Zealand, leaders have been praised for their decisive action. Some have attributed the success of these countries to their female leaders.6Forman R Atun R McKee M Mossialos E 12 lessons learned from the management of the coronavirus pandemic.Health Policy. 2020; 124: 577-580Crossref PubMed Scopus (132) Google Scholar Meanwhile, the Jordanian Government suspended study in educational institutions and stopped religious gatherings in places of worship within 12 days of its first case.7Alsharaydeh I Rawashdeh H Saadeh N Obeidat B Obeidat N Challenges and solutions for maternity and gynecology services during the COVID-19 crisis in Jordan.Int J Gynaecol Obstet. 2020; (published online May 29.)https://doi.org/10.1002/ijgo.13240Crossref PubMed Scopus (12) Google Scholar Effective leaders ensure good coordination, given the socioeconomic and health dimensions of the pandemic. Learning from previous disease outbreaks, Singapore established a multiministry taskforce to centrally coordinate a whole-of-government response before it had any confirmed cases.8Lee VJ Chiew CJ Khong WX Interrupting transmission of COVID-19: lessons from containment efforts in Singapore.J Travel Med. 2020; 27taaa039Crossref PubMed Scopus (100) Google Scholar The creation of the National COVID-19 Monitoring Authority in Tunisia has brought together senior officials from all ministries to ensure compliance with measures across sectors, as well as coordination between regional and national committees.9OECDCOVID-19 crisis response in MENA countries. Organisation for Economic Co-operation and Development, Paris2020Google Scholar The Lebanese Government has developed a COVID-19 response plan that involves the private as well as the public sector.10Ministry of Public Health LebanonNovel coronavirus 2019.https://www.moph.gov.lb/en/Pages/2/24870/novel-coronavirus-2019-Date: 2020Date accessed: June 25, 2020Google Scholar Decentralised systems have at times been identified as a problem, although this may only be when combined with poor communication; despite initial delays, Switzerland has shown the effectiveness of mutual learning and integration between local decentralised approaches in its response to COVID-19.11Gaskell J Stoker G Centralised or multi-level: which governance systems are having a "good" pandemic?. London School of Economics and Political Science, London2020Google Scholar Science guides decisive and impactful actions by leaders in countries where success is being recorded in the COVID-19 response. Implementation of large-scale lockdown measures has substantially reduced the number of COVID-19 cases—eg, estimates suggest that 2·1 million more COVID-19 cases have been avoided in Italy because of lockdown measures.12Hsiang S Allen D Annan-Phan S The effect of large-scale anti-contagion policies on the COVID-19 pandemic.Nature. 2020; (published online June 8.)https://doi.org/10.1038/s41586-020-2404-8Crossref PubMed Scopus (918) Google Scholar Establishing testing capacity was part of the first stage of South Africa's response, and after easing of its national lockdown, contact tracing teams for tuberculosis control were redirected to proactive COVID-19 case finding, contact tracing, and monitoring quarantine compliance, which has resulted in community-based screening of almost 20% of the population.13Karim S The South African response to the pandemic.N Engl J Med. 2020; 382: e95Crossref PubMed Scopus (95) Google Scholar Ultimately, given that high-quality disease surveillance data are sometimes not readily available, decisions should be based on best available knowledge, while adapting to new information. Decisive leadership appreciates the need for trusted public communication. Although government action is necessary to implement wide-scale measures, individual behaviour rather than governmental action is also important in limiting the spread of COVID-19, with emphasis on the importance of ensuring individual rights.14Anderson RM Heesterbeek H Klinkenberg D Hollingsworth TD How will country-based mitigation measures influence the course of the COVID-19 epidemic?.Lancet. 2020; 395: 931-934Summary Full Text Full Text PDF PubMed Scopus (2322) Google Scholar, 15Kupferschmidt K Cohen J Can China's COVID-19 strategy work elsewhere?.Science. 2020; 367: 1061-1062Crossref PubMed Google Scholar In Jordan and Morocco, for example, the governments have harnessed the potential of information technology to set up a website9OECDCOVID-19 crisis response in MENA countries. Organisation for Economic Co-operation and Development, Paris2020Google Scholar and app16Baumann B Hoffmann A Digitilisation and the coronavirus in Morocco: from care to control? Heinrich Böll Stiftung.https://eu.boell.org/en/2020/04/09/digitalisation-and-coronavirus-morocco-care-controlDate: April 9, 2020Date accessed: June 25, 2020Google Scholar for epidemiological information and surveillance. Building trust requires clear and consistent communication based on reliable sources, thus promoting transparency and accountability. Political partisanship negatively affects health behaviours and policy preferences, thus impacting success or failure of the COVID-19 response.17Gadarian SK Wallace Goodman S Pepinsky TB Partisanship, health behavior, and policy attitudes in the early stages of the COVID-19 pandemic.SSRN. 2020; (published online March 27, 2020.) (preprint).http://dx.doi.org/10.2139/ssrn.3562796Google Scholar Factors that undermine trust such as political polarisation should be deliberately addressed by leaders. Effective communication needs to emphasise a shared identity against the COVID-19 threat. Finally, effective leaders believe in a partnership-driven solidarity response to the pandemic. It starts with adherence to the measures defined by the International Health Regulations (2005). Transparency in sharing data is crucial, as shown by South Korea, which shared relevant information with agencies such as WHO from its first confirmed case.18Shaw R Kim Y-k Hua J Governance, technology and citizen behaviour in pandemic: lessons from COVID-19 in East Asia.Prog Dis Sci. 2020; 6100090Crossref Scopus (318) Google Scholar More countries have shown solidarity in financial support, donations of medical supplies, and sharing expertise at this time of unprecedented crisis. Saudi Arabia, for example, has donated financially to pandemic response efforts,19Mamud I Al-Mohaimeed A COVID-19: utilizing local experience to suggest optimal global strategies to prevent and control the pandemic.Int J Health Sci (Qassim). 2020; 14: 1-3Google Scholar while Cuba has sent doctors to other countries to support their response.20Dalglish S COVID-19 gives the lie to global health expertise.Lancet. 2020; 3951189Summary Full Text Full Text PDF PubMed Scopus (121) Google Scholar Partnership among countries is essential for obtaining faster results in COVID-19 treatment and vaccine clinical trials and WHO is supporting global partnerships through its Solidarity Fund, COVID-19 Supply Chain System, and Solidarity Trial.21WHOWHO, UN Foundation and partners launch first-of-its-kind COVID-19 Solidarity Response Fund.https://www.who.int/news-room/detail/13-03-2020-who-un-foundation-and-partners-launch-first-of-its-kind-covid-19-solidarity-response-fundDate: March 13, 2020Date accessed: July 1, 2020Google Scholar, 22WHO"Solidarity" clinical trial for COVID-19 treatments.https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov/solidarity-clinical-trial-for-covid-19-treatmentsDate: March 18, 2020Date accessed: July 1, 2020Google Scholar A pandemic that presents a global threat requires all leaders to step up and cooperate in decisive action. In the months to come, in the EMR and beyond, our sustained effort to save lives and mitigate the socioeconomic impact of COVID-19 must promote the role of decisive, open, and compassionate leadership. In countries where large numbers of infections are still being reported, it is time that leaders acknowledge the importance of rapidly acting on the best available evidence with transparency, a responsibility that is particularly crucial in low-income and fragile settings. Leaders must act decisively in the COVID-19 response with whole-of-government and whole-of-society approaches. We declare no competing interests. We thank Rana Hajjeh, Maha El-Adawy, Richard Brennan, Vian Russell, and Wasiq Khan for their input to this Comment.