Mandated Actions, Legitimate Role-Bearers and Expected Actor Networks in the 1 Management of Infectious Disease Epidemics: The Case of Marburg Virus 2 Disease in Uganda.


 Background In many Sub-Saharan Africa (SSA) countries, epidemic management is characterized with inaction, confusion and friction among a multitude of participating organizations. This is partially attributable to the inability to customize international epidemic management actions and guidelines to local institutional architecture, agencies and relational contexts. This results into poor coordination and suboptimal epidemic management outcomes. Using the case of Marburg Virus Disease (MVD) in Uganda, we explored how to clarify responsibility and collaboration across a multitude of inter-dependent actions and actors during epidemic management. Methods In July 2018, we reviewed MVD management literature and documents to identify key expected actions and actors/agencies. Data was summarized by phase and action area of MVD management. In March 2019, a 2-round Delphi survey was then undertaken to; 1) validate the identified actions and 2) assign legitimate role-bearers to each of the validated actions. We used NetDraw in UCINet to elaborate the expected network structure among legitimate role-bearers across all the phases and four selected action areas. Results We validated 304 mandated actions and 79 legitimate role-bearers in MVD management in Uganda. Across the four phases and selected action areas of MVD management, there is a high variation in the identity and number of mandated role bearers. Overall, Ministry of Health headquarters (MoH-HQs), National Task Force (NTF), District task Force (DTF) and National Rapid Response Team (NRRT) are expected to be the most central agencies during MVD management. Across the four phases and the selected action areas, actors are expected to be networked using a core-periphery network structure.Conclusions There is a multitude of agencies required to work inter-dependently to accomplish the mandated actions for MVD management in Uganda. MoH-HQs, NTF and DTF are most central in the Ugandan context. It is imperative to build/maintain the information processing, decision making and command and control capacity of these central agencies. The study findings can be used as the basis for exploring compliance and deviation in mandated actions in future MVD epidemics. The methodological approach could be replicated to other infectious disease epidemics in Uganda and beyond.

system waits to detect and respond to the next epidemic, creating a vicious cycle of 1 epidemic detection and response. By design, therefore, the IDSR framework does not 2 build health systems' resilience to infectious disease epidemics, which we define as the 3 capacity of the health system to prevent, prepare for, respond and recover from the 4 effects of infectious disease epidemics (Kruk, Myers, Varpilah, & Dahn, 2015). 5 Secondly, in many LMICs like Uganda, there is no published guideline on how 6 tasks/mandates are allocated during epidemic management. When epidemics occur, 7 the commonly observed practice is either to reactively ask available potential actors to 8 indicate the actions they are willing to support or to randomly allocate actions to those 9 physically available actors. This practice does not perfectly match actor competences to 10 specific response actions. It also does not effectively allocate the available resources to 11 all the critical epidemic response actions. Commonly, the required epidemic 12 management actions are not comprehensively defined. Even where attempts to define 13 these actions have been made, the legitimate role-bearers have not been explicitly We identify three (3) theories as appropriate for the exploration of the challenges of sub-1 optimal epidemic management in LMIC settings. These are; 1) Coordination Theory, 2) 2 Network Theory and 3) Comprehensive Emergency Management Theory. 3 Coordination Theory 4 Coordination theory can be applied to predict, understand and influence the process 5 and outcomes of managing dependences between multiple actors. When multiple 6 dependences in form of actions and in form of role-bearers are required to deliver on a 7 single outcome, efficiency of the outcome will likely be constrained. To reduce the 8 likelihood of such constraints, certain structures and processes must be in place before 9 and or during the execution of interdependent actions by multiple role-bearers. These 10 structures and processes are generally referred to as coordination mechanisms. 11 Broadly, there are three coordination mechanisms. These are; 1) Hierarchy (which 12 includes Standardization of required inputs and processes, authority, command and 13 control), 2) Speeding-up information flow (for example through formal and informal 14 networking) and 3) Increasing the capacity for information processing (for example 15 centralization of information processing). To maximize the performance of inter- 16 dependent relationships, the positive contributions from these three broad categories of applied to predict, control and explain the functionality of networks. Provan  Brokerage and Core/Periphery as described by Nowell and colleagues and as shown in  Provan and Kenis also contend that different types of network structures are likely to be 8 more effective than others depending on certain contingencies. Such contingencies 9 include the level of trust among actors in the network, the number of actors in the 10 network, the level of goal consensus among the actors in the network and the capacity 11 of these actors to operate in a network (Provan & Kenis, 2008). 12 Comprehensive Emergency Management Theory 13 Comprehensive Emergency Management Theory is premised on the coordination 14 mechanism of standardization (Whittaker, 1979). Standardization as a coordination 15 mechanism requires prior identification of all the required emergency management actions, allocation of these actions to specified role-bearers and developing the capacity 1 of these role-bearers to deliver on their mandated actions. This is the theoretical 2 underpinning of the Emergency Management Cycle (EMC) Model (Waugh, 1999;3 Whittaker, 1979), which has been found effective in the management of natural 4 disasters like floods and earthquakes (Banipal, 2006;FEMA, 2001). 5 The EMC model specifies four phases of modern emergency/disaster management. 6 These are; 1) Mitigation (actions that prevent a disaster and reduce the chance of it 7 happening, or lessen its damaging effects); 2) Preparedness (actions taken before 8 impact, including development of response plans), 3) Response (actions taken during 9 the initial impact of a disaster, including those to save lives and to prevent further 10 damage to property) and Recovery (actions taken after the initial impact, including those 11 aimed at achieving a return to normality). When the required/mandated actions and the 12 legitimate role-bearers for each of the EMC phases are agreed upon a priori, 13 coordination of emergencies/disasters tends to be more effective compared to when this 14 is not done in advance. Prior assignment of roles creates collaboration, preparedness 15 and clarity; which are all critical to effective emergency management. 16 The study makes a contribution to improved coordination of multiple actions and actors  Search strategy 8 We searched online databases using multiple online search strings constructed by 9 combining the terms Marburg, Virus, Disease, Mitigation, Prevention, Preparedness, 10 Response, Recovery, Stakeholders, Actors, Actions, Uganda, WHO, CDC, Outbreak, 11 Epidemic and Resilience. The databases searched included Google, Google Scholar, 12 Pub-Med and Medline. The official websites for WHO, CDC, UNICEF, MSF and MoH- 13 Uganda were also searched for official MVD management related documents. The 14 Uganda Public Health Emergency Operations Centre (PHEOC) also provided 15 documents that were collected during the 2017 Joint External Evaluation (JEE) of 16 International Health Regulation (IHR) core capacities for Uganda.

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Screening of retrieved Literature and Documents

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The process and outcomes of screening of the retrieved literature and documents is 19 summarized in Figure 2. First, all the retrieved documents we put into one folder, 20 removed duplicates and screened for relevance of each document by reading their 21 abstracts/executive summaries only. Sixty (60) documents were maintained for full reading. The 60 documents were each reviewed separately by two independent 1 researchers (NR and TKA) who abstracted MVD management actions and any role-2 bearers indicated in these documents. 3 4 Any data discrepancies between the two reviewers were resolved by conducting a joint 5 review of the source documents in question. The abstracted data was summarized in 6 excel into a single action-actor matrix with descriptors of phase (Mitigation, 7 Preparedness, Response and Recovery) and action area (as reflected in column 2 of   Round one of the surveys was a face to face half-day workshop. During this survey, the documented. We shared the study findings at a national level stakeholder dissemination 10 workshop.

Phase Action Area Actions Main Actors (No of actions) Mitigation
Capacity  In Uganda, just like it is in many LMICs, management of epidemics should be 3 collaborative endeavor. This is because no single Ministry, Department or Agency 4 (MDA) has the required jurisdictional authority, legitimacy, resources and technical 5 capability to effectively assume command and control of epidemic management alone. 6 By extension, government entities require collaboration with non-state actors such as 7 development partners, private sector and civil society organizations. The requirement to 8 operate interdependently however comes with the inherent challenge that 9 interdependence often reduces the efficiency of outcomespartly due to increase in

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We identified, validated and customized a total of 304 actions expected to be 19 implemented across the four phases of MVD management in Uganda. All the 20 synthesized actions (304) were assigned to specific legitimate lead and led (other) role 21 bearers. We were not able to find any published literature against which to compare whether the determined number of MVD actors (and actions) was small, medium or 1 large. Also, we were not able to find any evidence from Uganda or other LMIC setting 2 on comprehensiveness of allocation of the multiple actors to all the required actions for 3 management of MVD or any other epidemic. Elsewhere, previous studies have however 4 indicated that prior identification of actors and clarification about their mandated roles 5 increases cross-institutional preparedness and response to complex health emergences  Expected networks of legitimate Role-Bearers during MVD management in Uganda 9 We elaborated and visualized the expected actor networks by the four (4)   any evidence yet as to whether this expected core-periphery structure of network 20 governance is observed during actual MVD management in Uganda.
Provan and collegues argue that there are certain critical contingencies that can be 1 used to predict which type of network governance structure would be more effective.  16 The expected quality of actor networks during MVD management in Uganda 17 The ego-centric quality of expected networks in the comprehensive management of 18 MVD in Uganda was determined. In ego-centric Social Network Analysis (SNA), there 19 are multiple metrics that can be used to report on the quality of a social network. We  17 We recognize that the actions elaborated in this paper will likely be more constant than 18 the elaborated actors. We also recognize that the elaborated actor interlinkages during 19 the four phases and 4 of the 26 action areas of MVD management need not to be rigid. 20 In fact, in the face of a rapidly changing complex emergency, ad hoc structures of actor

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The study findings can be used as the basis for exploring compliance and deviation in 13 mandated actions and legitimate role-bearers during the actual management of future 14 MVD epidemics in Uganda.

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To improve the effectiveness of MVD management, it is important to build the capacity 16 of the agencies at the center of MVD management in the core mechanisms of 17 coordination.

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The methodological approach employed in thus study could be replicated to other 19 infectious disease epidemics in Uganda and beyond to aid the management and 20 resilience of health systems in the face of future epidemics.

DGHS:
Director General of Health Services