The necessity for intra-action reviews during the COVID-19 pandemic

After the 2014–16 Ebola outbreak in West Africa, WHO proposed a blueprint list of priority diseases for research and development, based on their epidemic potential or the absence of countermeasures.¹ Among this list is disease X,¹ representing the emergence of a disease previously unknown to humans that could result in a serious global health emergency. COVID-19, the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is disease X.

As of Oct 6, 2020, there have been more than 35 million cases and 1 million deaths reported globally.² Many countries were not prepared to deal with a highly infectious respiratory pathogen and were caught off guard, including countries with recognised robust health systems. It is essential that countries evaluate their responses to COVID-19, including what could be improved in areas such as preparedness and response plans, and what worked well in activating those plans and dealing with the pandemic. Importantly, countries that seemed well prepared for such a threat need to identify the underlying causes of the challenges they faced.

As COVID-19 continues to spread worldwide with no vaccines yet available, a protracted pandemic, characterised by interspersed local resurgences of clusters of cases, is probable in the months ahead. Of the four components of the International Health Regulations Monitoring and Evaluation Framework, the after-action review is the only one that systematically reviews functional capacities and capabilities following a real-life event.³ WHO typically recommends that countries conduct an after-action review immediately or up to three months after the national declaration of the end of a significant public health event.³ However, countries across the world continue to face different transmission scenarios of COVID-19.⁴ Some countries appear to have consistently mitigated the spread and impact of COVID-19, while other countries have had persistent community transmission or are seeing a resurgence in cases following easing of community-wide public health and social measures. Given the protracted and unpredictable nature of the COVID-19 pandemic, countries might need to consider doing regular periodic reviews during the event. These reviews could help countries to continually reflect on their response and revise current national and subnational COVID-19 response strategies, as needed, to change the trajectory of the epidemic and minimise morbidity, mortality, and the direct and indirect effects on livelihoods.

The world has learnt a great deal about how to suppress COVID-19 transmission and reduce mortality among severe cases over the past 9 months. While COVID-19 transmission is being brought under control, countries are starting to slowly open up and resume economic activity. The way in which interventions are adjusted as countries move forward must be driven by data and experience.

WHO's Guidance for Conducting a Country COVID-19 Intra-Action Review,⁵ modelled after the WHO after-action review,³ is a country-led, facilitated discussion bringing together a small group of COVID-19 responders, including decision makers with knowledge of the public health response pillars under review, such as multisectoral coordination, surveillance, and diagnostic testing. The objective of the intra-action review is collective learning, in which responders can share experiences and identify current challenges and bottlenecks, as well as what actions are working. Through a root-cause analysis,⁶ responders and decision makers can then address system-level root causes and propose practical steps for immediate remediation of gaps and the institutionalisation of best practices for sustained improvement of the ongoing response. Although intra-action reviews can be done online or face to face, the online format is recommended to avoid the risk of COVID-19 transmission among participants, particularly in countries with community transmission.

The WHO guidance was developed with ten ready-to-use and customisable accompanying tools to ensure countries can easily plan and conduct an intra-action review.⁵ These tools include a concept note template, a facilitator's manual, a generic presentation, a database with more than 300 COVID-19 trigger questions (open-ended questions for facilitators to select from to stimulate reflection and discussion), a final report template, and a success story template, among others. Countries are encouraged to share their review findings through a final report or success story to enable peer-to-peer learning and sharing of best practices or new capacities implemented in-country. The intra-action review guidance is aligned to the current WHO COVID-19 Strategic Preparedness and Response Plan and its nine public health response pillars.⁷ In addition, a tenth pillar was also included in the guidance for other possible topics and cross-cutting issues, covering diverse topics relevant to the specific contexts of each country, such as caring for vulnerable populations in conflict zones and managing the spread of COVID-19 in camps for refugees or internally displaced people.⁸ Depending on the specific objectives and needs of the intra-action review, countries are encouraged to adapt and expand the pillars and trigger questions as required.

Many countries have had success in controlling transmission. However, some of these countries are starting to see a resurgence of cases again as they open up. Learning and sharing of the experiences and actions of one country can help others. This knowledge might help countries to more rapidly detect cases, prevent cases from becoming clusters, and clusters from turning into community transmission. One way to achieve this can be regularly doing intra-action reviews to ensure continual learning on best approaches to control this new virus and revise countries' response strategies, as needed. In the fourth meeting of the Emergency Committee under the International Health Regulations (2005), convened by the WHO Director-General on July 31, 2020, temporary recommendations were also issued to encourage countries to “share best practices, including from intra-action reviews, with WHO; apply lessons learned from countries that are successfully re-opening their societies and mitigating resurgence of COVID-19.”⁹ In line with these recommendations, WHO urges countries to plan and conduct intra-action reviews, while engaging country leadership to ensure accountability and leadership support, in a whole-of-society approach, as some countries have already started doing.¹⁰ The findings from intra-action reviews can inform decision making for immediate improvements of the response, as well as strategic and operational planning, such as updating national and subnational COVID-19 response plans. Through regular dialogue and learning via intra-action reviews among multisectoral responders and decision makers, we hope that countries can be increasingly adaptable in responding to the ongoing COVID-19 pandemic.