Introduction

The coronavirus disease 2019 (COVID-19) pandemic has challenged health systems and economies around the world; a public health crisis of such magnitude revealed that response measures cannot be taken by the health sector alone. The scope and complexity of the pandemic proved that no single agency can work alone to effectively control and mitigate its impact. Therefore, an effective response requires concerted multi-sectoral efforts that involve public, private and civil society actors within and beyond the health sector [1, 2]. In response, countries around the world have taken unprecedented measures to combat the spread of the COVID-19 pandemic while ameliorating its devastating impact on health, society and the economy.

It has been extensively discussed in the literature that tackling the multi-sectoral nature of health challenges requires structured multi-sectoral coordination including state and non-state actors, all of which are critical for shaping a more effective pandemic response, especially a pandemic of the magnitude of COVID-19. The approach of multi-sectoral action for health is widely recognized, with many national and international examples of multi-sectoral approach applications before the COVID-19 pandemic, such as for malaria elimination, tobacco control, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) prevention, Finland’s community‑based cardiovascular disease prevention project (North Karelia Project) and Singapore’s Health Promotion Board [3, 4]. However, successful initiatives in this area remain a challenge for countries worldwide, especially during such public health threats and in vulnerable settings.

The Eastern Mediterranean region (EMR) is distinctly affected by ongoing conflicts, political unrest and displacements. This has posed unique vulnerabilities during the COVID-19 pandemic not experienced in other parts of the world. Despite its unique characteristics, there is still a paucity of information concerning the patterns of multi-sectoral collaborations that exist in this region. It remains unclear to what extent multi-sectoral policies and programs have been adopted in the COVID-19 pandemic responses, including the mechanisms and governance arrangements in place to promote multi-sectoral policies and programs and the key sectors and actors involved.

This study aims to fill the aforementioned gaps by examining the extent to which multi-sectoral collaborations have been employed in the macro-level responses to the COVID-19 pandemic in selected countries of the EMR. The specific objectives are to [5] assess the extent to which a ‘multi-sectoral’ element was employed in the COVID-19 pandemic response in selected EMR countries and [6] explore enablers (i.e. barriers and facilitators) to multi-sectoral collaborations in responding to the COVID-19 pandemic. The significance of this study stems from its examination of whether multi-sectoral collaboration was an opportunity or missed opportunity for a more effective pandemic response in the EMR, identification of key gaps and generation of recommendations on how to promote multi-sectoral collaborations for future public health emergency responses in the EMR and beyond.

Analytical framework

A multi-sectoral approach refers to deliberate collaboration among various stakeholder groups (e.g. government, civil society and private sector) and sectors (e.g., health, environment and economy) to jointly achieve a policy outcome [3]. While the multi-sectoral approach is advocated as one of the strategies to address complex health and development challenges, there is limited clarity about the process and execution of multi-sector collaboration in practice [7].

To formalize multi-sectoral collaboration for this study, we constructed an analytical framework, building on a suite of existing frameworks on multi-sectoral approaches and action for health, policy analysis and social development [7,8,9,10,11,12,13] and drawing from the literature on policy responses to the COVID-19 pandemic [1, 14,15,16,17]. The framework encompasses key components and elements critical in a process of multi-sector collaboration (Table 1).

Table 1 Analytical framework for multi-sectoral approach to pandemic response
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This framework was used to analyse the macro-level pandemic response plans in selected EMR countries. For each component, we assessed the extent to which the desirable elements were present and the variations within and across the selected countries.

Methodology

The study employed an in-depth analytical research design and was conducted in two phases. In the first phase, data were collected using a comprehensive documentation review. In the second phase, key informant interviews were conducted to validate findings from the first phase and gain additional insights and feedback.

The WHO’s classification of the EMR countries was adopted, which includes: Afghanistan, Bahrain, Djibouti, Egypt, the Islamic Republic of Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, the Occupied Palestinian Territories, Qatar, Saudi Arabia, Somalia, South Sudan, Sudan, Syrian Arab Republic, Tunisia, the United Arab Emirates and Yemen [18]. For the purpose of this study, we selected the following nine EMR countries:

  • High-income countries (group 1 countries): Bahrain, Saudi Arabia, United Arab Emirates

  • Middle-income countries (group 2 countries): Jordan, Lebanon, Tunisia

  • Low-income/fragile countries (group 3 countries): Sudan, Syria, Yemen

The nine selected countries represent different income groups (i.e. high-income, middle-income and low-income countries, according to World Bank categorization 2021). They also reflect the three different groupings of EMR countries by the WHO (i.e. group 1, group 2 and group 3 countries) on the basis of population health outcomes, health system performance and level of health expenditure [19].

Data collection

The data collection process for this study employed a mix of document review and key informant interviews.

Document review

This step involved a review of policy documents, protocols, guidelines, strategic plans and programs, legislative acts, national-level reports and research papers to collect data on the different components of the framework. Documents were identified and obtained from websites of governmental bodies, ministries, departments and public agencies of each country. Additionally, we searched the websites of key intergovernmental organizations (e.g. UNDP, UNHCR, WHO, ICRC, UN, World Bank), think tanks, research institutions and universities for relevant reports and studies. We also reviewed key media outlets for relevant news articles on the pandemic response from each selected country.

PubMed and Google Scholar were also searched to retrieve scholarly and peer-reviewed articles using the following search strategy for each country: (“novel coronavirus” OR COVID-19 OR pandemic OR SARS-COV-2) AND (response OR government OR intervention* OR policy OR policies OR national OR “cross-sectoral” OR program* OR intersectoral OR “multi-sectoral” OR governance OR collaboration* OR coordination OR “whole-of-government”) AND ([country name]).

The data collection through document review spanned from January 2020, when the first COVID-19 case was detected in one of the nine countries, to May 2023, when the WHO declared the end of COVID-19 as a global health emergency.

Retrieved documents were reviewed and findings pertaining to the component (and elements) of the framework were abstracted and summarized in a unified excel sheet.

Key informant interviews

Key informant interviews were conducted with selected experts/stakeholders from the included countries. The interviews served two purposes: to validate the findings emerging from the documentation review (and fill gaps identified); and to gain additional insights on key barriers, facilitators and lessons learned from promoting multi-sectoral collaboration in the COVID-19 pandemic response. An interview guide was developed, informed by the conceptual frameworks.

We adopted the following stakeholder sampling framework to ensure the selection of right mix of participants for the study [20]:

  • Senior- and middle-level policymakers from the public sector;

  • Representatives from professional associations who are active in trying to shape and influence health policies

  • Researchers who are active in the realm of health systems research and/representatives from university departments and faculties that produce public health and health systems research;

  • Representatives of the non-state sector who are active in trying to shape and influence health policies.

We purposively mapped stakeholders from the selected countries against the framework. We targeted those stakeholders who participated in the COVID-19 policy process, including policymakers involved in national pandemic policies and response plans; NGOs involved in COVID-19 programs; and researchers/academia informing the COVID-19 response. A total of 24 stakeholders were initially selected and invited to participate in the study. Following two reminder emails, eight participants (three policymakers, two researchers, one public health expert, one representative from EMR Public Health Network and one senior representative from an intergovernmental organization) agreed to take part in the study. Participants represented the following low- and middle-income countries: Jordan, Lebanon, Sudan, Syria, Tunisia and Yemen.

The meetings were conducted virtually (on Zoom) by the lead researcher (F.E.J.) or co-lead researchers (R.F., N.D.) and lasted between 40 min and 60 min each. Responses were documented through note-taking by the researchers (R.F., F.E.J., N.D.).

The key informant interviews were conducted between October 2020 and March 2021.

Data analysis and synthesis

The data generated from the documentation review and key informant interviews were collated and analysed in aggregate form and categorized according to the seven components of the analytical framework (Table 1); meaning that findings were analysed according to components of the framework rather than by source of data. We used a deductive content analysis approach to synthesize data, which is appropriate for policy-relevant qualitative data [9, 21]. This approach uses an analytical framework featuring key constructs and variables as initial coding categories while leaving room for other emerging themes outside the framework.

The first stage of data analysis comprised analysing and coding data obtained from the documentation review according to each of the seven components of our set framework. Once the findings from the documentation review were coded, the interviews with stakeholders were conducted. The purpose of the interviews was to validate the findings generated from the first step of analysis and obtain additional insights about each component of the analytical framework. Findings from interviews were also coded according to the analytical framework adopted for this study. Emerging themes were compared with those from the documentation review, and information was added or validated where appropriate.

Data triangulation helped provide a more in-depth understanding of the issue and increase the reliability and validity of findings through cross-checking of information across different data sources.

The study was conducted following standard ethical guidelines and protocols. Participation in this study was voluntary. A verbal consent form was provided to participants prior to commencing with the interviews. The confidentiality and anonymity of responses were ensured at all times. No names or identifiers were linked to any of the findings emerging from the study.

Results

Findings are presented according to the components described in the analytical framework: (1) context and trigger; (2) leadership, institutional mechanisms and processes; (3) actors; (4) administration, funding and evaluation; (5) degree of multi-sectoral engagement; (6) impact; and (7) enabling factors.

Context and trigger

Healthcare system

The EMR represents a diverse landscape of healthcare systems and political structures, each shaped by unique historical, socio-economic and political factors (Table 2). Among the nine selected EMR countries, high-income countries such as Bahrain, Saudi Arabia and the United Arab Emirates possess robust healthcare systems underpinned by strong financial backing and effective governance [22,23,24]. In contrast, countries such as Lebanon, Tunisia and Jordan face a multitude of challenges, including political instability, economic uncertainties, a high influx of refugees and relatively less efficient healthcare systems [25,26,27]. Conflict-affected countries such as Sudan, Syria and Yemen, already burdened by other disease outbreaks, famine and malnutrition, relied heavily on humanitarian assistance from donor nations and non-governmental organizations for resources [28, 29].

Table 2 Health systems, political structures and COVID-19 situation in selected countries
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Political structures

Table 2 provides an overview of the political structure in the nine selected countries. Lebanon stands out as a parliamentary democracy, distinguishing itself from the others. Bahrain, Saudi Arabia, the United Arab Emirates and Jordan operate under a monarchy system. Tunisia experienced a notable shift from a representative democracy to an authoritarian state in 2021. Meanwhile, political conflicts in Sudan, Yemen and Syria have led to a weakened political structure and fragmented governance.

Trigger (COVID-19 situation)

The COVID-19 pandemic, with its rapid and pervasive spread, exposed the strengths and weaknesses of healthcare systems across the EMR. The first confirmed case in the region was reported in the UAE on 29 January 2020, marking the beginning of the pandemic’s relentless march across the EMR [72]. Within a short period, all nine selected countries had recorded their first cases, highlighting the urgent need for immediate and effective public health responses (Table 2). The sweeping scale, breadth and impact of the pandemic rendered it of utmost priority. The recognized interdependencies amongst sectors and the need to work with others triggered the establishment of multi-sectoral collaboration in response.

The functioning of multi-sectoral collaboration varied across the region. Saudi Arabia, Bahrain and the United Arab Emirates, characterized by monarchical governments and robust healthcare infrastructure, implemented swift and efficient measures, including widespread testing and early lockdown protocols. Despite its monarchical system, Jordan faced challenges in responding to the pandemic due to limited healthcare preparedness and the strain of hosting a large refugee population [73]. On the contrary, countries with political and economic instability struggled with fragmented and often delayed responses [55, 59, 66]. Lebanon’s private-sector-dominated healthcare system and persistent political turmoil, exacerbated by inadequate accountability mechanisms, contributed to insufficiencies in the healthcare system and impeded a cohesive response, while Tunisia’s political transition from a representative democracy to an authoritarian state affected its healthcare response and resource allocation [26, 27, 46]. In countries with fragmented governance structures and weak healthcare systems such as Sudan, Syria and Yemen, the lack of coordination between government agencies and non-health sectors weakened the pandemic’s impact, particularly in terms of resource allocation and service delivery. These disparities were evident in the early phase of the pandemic, as COVID-19 outcomes diverged significantly across the EMR [74,75,76]. UAE and Bahrain recorded lower case fatality rates (0.32% and 0.38%, respectively) during the first year of the pandemic. In contrast, Yemen had the highest case fatality rate (29%), followed by Syria (6.2%) and Sudan (5.75%) (Table 2).

Leadership, institutional mechanisms and processes

Leadership role

Since the confirmation of the first COVID-19 cases in the EMR in late January 2020, the nine countries selected for this study have developed national preparedness and response plans as part of the multi-sectoral COVID-19 response. In the majority of the high-income (Bahrain, UAE) and middle-income (Jordan, Tunisia) countries, the multi-sectoral response has been led by the government through the engagement of the prime minister’s offices, high governmental and ministerial councils, or offices in charge of crises of national concern. In contrast, the response in low-income countries (Sudan, Syria, Yemen) has been led by intergovernmental agencies [specifically United Nations (UN) entities and WHO] in collaboration with respective ministries of health, which did not permit significant interactions among other government departments (see Table 3).

Table 3 Leadership, institutional mechanisms and processes for multi-sectoral collaboration
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Coordination mechanisms

In the majority of the selected EMR countries, coordination mechanisms were established to facilitate interaction between sectors and actors. Specifically, the formation of coordination committees at the level of the prime minister’s or president’s office, or cross-ministerial committees at the ministry level, were identified as the primary mechanisms through which these forms of multi-sectoral action were realized. However, the mandate and influence of these committees varied, with uncertainties regarding how they functioned, particularly in terms of the closeness of the cooperation and the working methods (Table 3). Coordination structures lacked a clear mandate, joint costed action plan, adequate resources and regular reporting on commitments. Additionally, there were no explicit processes for conflict management and building trust among stakeholders.

Communication structures

Beyond bringing sectors together, effective collaboration requires sectors to communicate and engage in meaningful participation, both internally and externally with the public. In the majority of the selected countries, regular meetings were reportedly being held (either in person or online), some of which were followed by press briefings. However, there was no evidence of robust communication planning, including strategies for promoting consensual decision-making and managing power dynamics in conversations (Table 3).

The COVID-19 pandemic also underscored the importance of knowledge generation and utilization in driving effective responses. This process, however, faced significant challenges, such as scientific uncertainties, the spread of misinformation and weak collaborations among stakeholders [77]. Various government initiatives aimed to combat misinformation and disseminate accurate information through hotlines, websites and media collaborations with health experts [78, 79]. Despite these efforts, their effectiveness was often compromised by factors such as limited government capacity, perceived corruption and non-transparent decision-making processes. Particularly, in conflict-affected countries such as Sudan, Syria and Yemen, the national governments’ weak capacity and perceived corruption undermined the legitimacy and trust in pandemic response authorities [28, 29]. Throughout the pandemic, some of these countries were still withholding COVID-19 data, influenced by a lack of political will and underdeveloped digital data collection systems. This "secrecy" and institutionalized opacity eroded public trust and hindered a successful multi-sectoral response.

Actors

Given the scale and breadth of the COVID-19 pandemic, a whole-of-government, whole-of-society approach was needed to respond effectively. Actors from three critical sectors – public, private and civil society – have been involved in the response of the nine selected countries, albeit to varying degrees; furthermore, roles and responsibilities among actors in the collaborative arrangements have not been clearly defined nor linked to a mandate for a more effective multi-sectoral response.

When it comes to state actors, there was a strong representation of different ministries in the national responses of the nine selected countries. The prime minister’s office was also involved in many cases (Table 4). Conversely, the contribution of non-state actors, including non-governmental organizations (NGOs), civil society organizations (CSOs), the private sector, the media and citizens, was relatively modest in most of the selected countries, with the exception of Sudan. The nature of these initiatives varied depending on the context. In cases in which governments exhibited weakness, such as in Lebanon, non-state actors often took the lead in initiating and carrying out relief efforts [80, 81]. Conversely, in contexts in which governments maintained a strong presence, such as in Bahrain, Saudi Arabia and United Arab Emirates, non-state actors’ involvement was often prompted or initiated by government initiatives [82,83,84,85].

Table 4 Sectors and actors involved in the COVID-19 pandemic response
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The involvement of intergovernmental organizations (e.g. WHO, UN entities) and CSOs was more prominent and proactive in low-income countries (e.g. Sudan, Syria, Yemen) and countries with a high number of refugees (e.g. Jordan, Lebanon) where they already had a strong presence prior to the pandemic. In these settings, non-state actors leveraged their existing presence and expertise to complement government initiatives and address gaps in awareness-raising and community outreach. In contrast, non-state actors’ involvement in high-income countries were largely prompted by the government [82,83,84,85] (Fig. 1). The United Arab Emirates provides a notable example of private sector engagement in the pandemic response. For instance, the country launched the first United Nations Alliance for Disaster Resilient Societies (ARISE) initiative in the region, coordinating and maximizing private sector involvement in disaster management [86]. Additionally, government and private sector entities collaborated to support residents’ mental health needs during the crisis by providing access to free support services, such as hotlines, webinars and counselling [86].

Fig. 1
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Involvement of non-state actors and their roles in the COVID-19 pandemic response

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While COVID-19 has increased the need for experts in various public health disciplines to plan suitable programs and responses, the selected countries of the EMR have registered only modest initiatives from public health experts, whose engagement has not been systematically integrated. Similarly, the role of researchers and academia has not been well integrated into the national pandemic responses. Only in three of the countries studied (KSA, UAE and Tunisia) did the government allocate funds for COVID-19 research as part of the national response (Fig. 1).

Administration, funding and evaluation

Every collaborative needs effective administrative practices, adequate financial resources and a plan for regular monitoring and evaluation [7]. Below, we elaborate on each of these elements with respect to the multi-sectoral response in the selected countries.

Administration of the multi-sectoral response

In the majority of the selected high- and middle-income countries of the EMR, the organization of the COVID-19 response was highly centralized, owing largely to the centralization of health services. Those countries with centralized governance and strong leadership, such as Jordan, KSA, Bahrain and the UAE, were able to swiftly coordinate and mobilize resources across various sectors. Conversely, in countries with fragmented governance or weak leadership, such as Syria, Sudan and Yemen, multi-sectoral collaboration was often hindered by conflicting priorities, the emergence of multiple power centres and a lack of clear direction.

While a centralized approach may be logical in addressing a crisis of such scale, it is also crucial to harmonize and integrate the top-down approach with local-level actions and implementation. This emphasizes the importance of considering local context and involving communities in the implementation of policy intervention. Poor governance coherence has been attributed to factors including a lack of legitimacy of authority and trust in leadership, and the absence of clear mechanisms to translate high-level policies and regulations into practical measures that can be implemented, enforced and monitored at the local level.

Financial resources

The amount and source of funding dedicated to the national response differed across the nine selected countries. Unsurprisingly, governments in high-income countries (Bahrain, KSA and UAE) invested the highest amounts [87,88,89]. Next were upper-middle-income countries (Jordan, Lebanon and Tunisia) where, in addition to government’s dedicated funds and foreign support, several platforms were established to raise funds from public donations to support the response. In contrast, low-income countries (Sudan, Syria and Yemen) were reported to have insufficient financial resources to develop policies and engage multiple sectors in implementation activities. Consequently, these countries tended to heavily rely on external funders and donors (Table 5). With the exceptions of the UAE and Jordan, none of the selected countries offered clear information on the cost-sharing mechanisms between sectors for specific components of the plan.

Table 5 Overview of funding, monitoring and evaluation and accountability mechanisms in selected countries
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Across the nine selected countries, it was not clear to what extent budgeting for activities of the collaborative was a multi-sectoral activity, undertaken by all sectors (and stakeholders) involved. And while the budget covered the policy interventions under the response plan, there was no explicit reference to the expenses incurred to run the coordination mechanisms at national and subnational levels.

Monitoring and evaluation

Collaborative progress needs to be monitored through an accountability framework consisting of indicators related to both process and outcomes, pegged to the objectives of the joint action plan. With the exceptions of Syria and Yemen, most countries had mechanisms in place and designated entities for reporting on progress; however, only a few countries incorporated explicit indicators for monitoring and evaluation into their national response plans (Table 5). Furthermore, none of the countries included indicators to monitor the process of the collaborative itself. Information on the mechanism and designated entity for monitoring and evaluation were not identified for Jordan and KSA. In all cases, it was unclear to what extent monitoring and evaluation were formally being conducted on the ground.

While accountability is an essential governance element in collaboratives, critical for building trust and enhancing effectiveness, none of the selected countries incorporated an explicit accountability framework or integrated anti-corruption and counter-fraud measures into their multi-sectoral plans or coordination mechanisms. A recent report conducted in the region highlighted corruption risks in public procurement and privately donated funds, and urged governments to adopt transparency and accountability measures to provide much-needed anti-corruption oversight [90].

Degree of multi-sectoral engagement

Multi-sectoral engagement lies on a spectrum, from more passive to active involvement. It can range from communication, in which information from one sector is shared with other sectors; to cooperation, which involves optimizing resources while establishing formalities in the work relationship; to coordination, in which there is increased horizontal networking among sectors with some sharing of financing sources; and to integration, which entails systematic integration of objectives and administrative processes and the sharing of resources, responsibilities and actions [13].

Across the selected EMR countries (and based on the findings from the documentation review and stakeholders’ inputs), the degree of multi-sectoral engagement between sectors and actors spanned the spectrum from communication to cooperation and coordination; it rarely went further to integration, which necessitates formal partnerships and shared policies and practices to ensure achievement of a common goal. Although low-income countries witnessed the engagement of sectors outside the health sector, this engagement seemed mostly limited to providing information or viewpoints and was not a truly collaborative effort. Across middle-income countries, the engagement could be classified as cooperation, involving formal meetings and regular exchange of staff, information and practices. As for high-income countries, the engagement went further, to coordination with sharing on regular formal bases and regular exchanges and specific undertaking on shared projects. Table 6 provides a visual representation of the degree of multi-sectoral engagement across the selected countries.

Table 6 Degree of multi-sectoral engagement across selected countries
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Impact

Strong multi-sectoral collaboration has been shown to yield a more effective pandemic response [1, 91]. Across the countries selected, those with a stronger degree of multi-sectoral engagement (see Table 6) seem to adopt a more comprehensive set of COVID-19 measures or interventions and achieve better COVID-19-related outcomes (see section Comprehensiveness of policy measures and responses and Box 1, respectively). However, it is important to caution that this study does not claim any cause–effect relationship. Other factors may also have contributed to the observed variations, including population demographics, prevailing political structures, disparities in health system capacities and cultural factors ranging from high levels of socialization to distrust in public institutions, which might influence compliance with public health measures.

Box 1: Case Study on Active Surveillance and Contact Tracing in the selected EMR Countries

The varied approaches employed in active surveillance and contact tracing – a cornerstone of public health responses – exemplify the diverse challenges and capacities among the selected EMR countries in managing public health crises such as the COVID-19 pandemic

• In high-income countries such as Bahrain, Saudi Arabia and the United Arab Emirates, robust digital surveillance is exemplified through the health electronic surveillance network, which significantly aided in disease detection, response and community health monitoring [5, 6, 103, 104]. The “Tawakkalna” application, developed by the government in Saudi Arabia, played a pivotal role in tracking infections, saving lives and reducing the strain on health facilities [5, 6]. Similarly, Bahrain introduced the BeAware Bahrain app, leveraging cloud technologies and location tracking to identify and alert individuals in contact with COVID-19 cases [104]. The United Arab Emirates implemented a comprehensive strategy focusing on mass testing, contact tracing and isolating positive cases. Early adoption of this strategy in April 2020 contributed to a lower-than-expected mortality rate [103]

• Middle-income countries (Lebanon, Jordan and Tunisia) faced challenges due to limited capacity in detecting, tracing and isolating COVID-19 cases [45, 105, 106]. Factors such as under-resourced surveillance systems, delayed diagnostic scale-up, inadequate isolation facilities and the absence of digital contact tracing contributed to underestimation of community spread and hindered informed decision-making. Lebanon, for instance, heavily relied on a single hospital for testing, isolating and treating confirmed cases during the early stages of the pandemic, which undermined the overall response [45]

• Low-income countries such as Sudan, Syria, and Yemen faced significant challenges attributed to security concerns and limited accessibility [107,108,109]. The absence of a unified, digitalized health information system hindered the tracking of the pandemic’s evolution and response. Sudan, for instance, grappled with a shortage of isolation centres and testing capacity, underscoring the broader difficulties in managing the pandemic in such contexts [108]

Comprehensiveness of policy measures and responses

Governments in the EMR have responded differently to the pandemic, with variations in reaction speed and strictness of implementation. Collectively, country responses ranged from public health measures such as lockdowns, social distancing and contact tracing to social interventions and broader fiscal policies to restore the economy. These responses continued to change over time as countries experienced second waves of outbreaks or recovered from major bouts of infection. While all selected countries implemented a range of public health measures, variations across income groups were more pronounced in terms of the comprehensiveness of adopted social and economic measures (Fig. 2).

Fig. 2
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Overview of public health and socio-economic measures adopted by selected EMR countries during the first year of the pandemic (i.e. year 2020)

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Across income groups, policy measures were most comprehensive in high-income countries, followed by middle-income countries, with the least number of measures adopted in low-income countries. Box 1 illustrates the varied approaches employed in active surveillance and contact tracing among the selected countries in the EMR.

The overall pandemic response in the EMR can be grouped into three broad types:

Early response, proper measures and successful implementation: KSA, UAE and Bahrain

KSA began taking precautionary actions early in January even before WHO declared COVID-19 a pandemic. The whole-of-government approach adopted in KSA at the national level allowed the right decisions to be taken on time and to be implemented promptly and in a coordinated manner. The UAE was the first country in the EMR to report a COVID-19 case; in late January 2020. The UAE had a clear strategy that relied on communication and coordination, with no room for rivalry, opposition or dissonance; this has allowed the country to rise to the forefront of effective decision-making. In fact, it ranked among the world’s top 10 for COVID-19 treatment efficiency and among the world’s top 20 for the implementation of COVID-19 safety measures [92]. Similarly, the WHO’s Eastern Mediterranean office commended Bahrain’s swift and effective countermeasures against COVID-19 as an example that other countries should follow [93, 94].

Successful handling of the first wave, but lost control later: Jordan, Lebanon and Tunisia

Jordan’s response to the pandemic was one of the strictest in the region and among the world in the first months of the outbreak. Later, after easing lockdown measures, Jordan witnessed a gradual increase in confirmed cases of COVID-19 by early August 2020. Similarly, Tunisia and Lebanon’s initial response highlighted their inability to manage a crisis of such severity. Tunisia managed to successfully control the initial epidemiological threat posed by the pandemic, with the second-lowest fatality rate in the region [95]. However, the government was not as proactive as it could have been, effectively implementing needed measures almost two weeks after the confirmation of the first COVID-19 case. As for Lebanon, at the start of the pandemic the government was successful in handling the response; however, after the Beirut port explosions on 4 August 2020, the response got out of control and cases began to skyrocket [47, 96, 97]. This has been attributed to the failure of the government to develop a long-term strategy and the breakdown of communication across sectors.

Failed response due to crippling war: Yemen, Syria and Sudan

The pandemic has hit Sudan, Syria and Yemen at a critical time, leaving the authorities in each of these countries struggling to deal with the newly imposed public health threat. Yemen was one of the last countries worldwide to announce the first confirmed case of COVID-19 infection among its population, and 1 year after the start of the pandemic, Yemen had the lowest publicly reported infection rate in the region and the highest case fatality rate in not only the region but the world [98, 99]. Syria had no official number of COVID-19 tests conducted until 16 March 2020, with only 103 tests reported in government-held areas. Despite the low reporting, many indicators suggested that Syria already had a considerable number of COVID-19 cases prior to the announcement of the first official case on 22 March 2020 [100,101,102]. The lack of transparency and weak reporting system in these three countries has affected the national COVID-19 response and led to confusion and mistrust at different levels of decision-making, undermining multi-sectoral action.

Selected COVID-19-related outcomes

As of 5 May 2023, when the WHO declared an end to the COVID-19 pandemic as a public health emergency [110], a cumulative total of 7 million confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and 78,000 COVID-19 deaths had been reported across the nine selected countries of the EMR. By the end of the pandemic, Bahrain had the highest percentage of COVID-19 cases out of the population (40.8%) followed by Lebanon (18.6%), then Jordan (16.9%). Yemen had the highest case fatality rate (CFR) at 18%, followed by Sudan (7.9%), then Syria (5.5%). In contrast, UAE and Bahrain registered the lowest CFRs, both at 0.2% (Fig. 3).

Fig. 3
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Covid-19-related outcomes in selected EMR countries (as of 5 May 2023) [74,75,76, 111,112,113]

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UAE and Bahrain also conducted the highest number of tests per million population, while Syria conducted the fewest. As for the percentage of positive COVID-19 cases out of the total tests conducted, Yemen had the highest percentage (113%) followed by Syria (39.5%), Lebanon (25.8%) and Tunisia (23%). The WHO recommends a positivity rate of around 3–12% as a general benchmark indicating adequate testing [108]. A high positivity rate indicates that the country is not testing widely enough to find all cases, and the actual number of circulating cases in the community is far higher than the confirmed numbers.

Regarding vaccination, UAE had the highest percentage of its population fully vaccinated (100%), followed by Bahrain (83.3%) and KSA (69.9%). Yemen, Syria and Sudan had the lowest vaccination rates, with 2.3%, 10.7% and 28.6%, respectively (Fig. 3).

It is important to account for the inconsistencies in methodologies used to report cases among countries due to internal and external factors. For instance, given the limited testing activity and capacity across Syria, Sudan and Yemen, and the lack of credible information sharing and transparency, the actual number of cases likely exceeds available official figures.

Enabling factors

Key reported barriers

Barriers to multi-sectoral action were more acute in the fragile countries selected for this study (Syria, Sudan and Yemen) and to a lesser extent in middle-income countries (Lebanon, Jordan and Tunisia) where weak institutions, sectoral bureaucracy and fragmentations have undermined coordination. This is in contrast to high-income countries (KSA, UAE and Bahrain) where health system infrastructures are more advanced, robust multi-sectoral structures existed prior to the pandemic and resources were available to quickly activate the existing multi-sectoral structures or establish new ones as part of the response to the newly imposed public health threat.

One of the most recurrent barriers was the fragmentation of authorities and the multiplicity of actors in charge of the pandemic response, which created confusion and undermined public trust in the pandemic response. This was more pronounced in conflict-affected countries of the EMR where national governments often suffered from perceived lack of legitimacy by opposing parties internally as well as by other governments and international actors. Key informants raised these concerns and further highlighted the lack of a mandate defining the roles and responsibilities of each sector, as well as a lack of clear ownership. Additionally, amidst the lack of mechanisms for conflict management and building trust as part of the national pandemic response, key recurrent challenges included competition over resources and conflicts between sectors and actors at different levels, especially in fragile countries where political consideration was prioritized over the health of the population. In many cases, political, personal and financial interests were reported to be at the core of these conflicts, which hindered the willingness of different actors to carry out and sustain inter-sectoral action.

Siloed thinking and resistance to adopting multi-sectoral perspectives were also highlighted as challenges that apply to the health sector, as well as to other sectors. This is mainly attributed to the limited understanding of the importance of multi-sectoral collaboration and how best to promote and support multi-sectoral action for health at the national level. As re-iterated by participants, multi-sectoral action is still a new concept for the majority of governments in the EMR, where working in silos is still the norm. This is also related to the limited awareness about the wider determinants of health and that the responsibility of responding to health problems lies beyond the mandates of the Ministry of Health.

Another main concern raised was the lack of processes for accountability and monitoring. In fact, 1 year after the start of the pandemic, some countries in the EMR were still not making their COVID-19 data public, or were not sharing the information, models and assumptions upon which decisions were made. Consequently, this ‘perceived secrecy’ has undermined public trust in many leaders and negatively affected the goal of reaching a successful multi-sectoral response. The implementation of accountability mechanisms and monitoring frameworks was seen to be difficult and sometimes impossible, especially in countries where entrenched political and administrative corruption was reported. A lack of accountability within the same department or ministry was also reported, and not only across the different ministries involved in the response (i.e. lack of vertical and horizontal reporting and accountability). This further hindered the effective translation and implementation of guidelines and high-level recommendations into practice at the local levels.

Participants noted that coordination at the beginning of the pandemic was more robust as compared with 1 year later, hence failure to sustain the multi-sectoral response for coordinated efforts was one of the main challenges experienced. As highlighted by some participants, it was difficult to maintain the active involvement of all sectors, state and non-state actors in implementing the policy response over a long period of time, as the perceived threat started to decrease as well as the available funds, with economic considerations taking precedence over public health concerns. In fact, it was noted by several participants that the inadequate finances and the over-reliance on external donors to support implementation capacity meant that policies and responses were not being implemented in a sustainable way. Furthermore, inadequate anchoring of the multi-sectoral governance structure within government in some of the selected countries undermined their convening power and ability to secure a budget line item.

The prevailing political context has been another reported factor influencing multi-sectoral collaboration. In Lebanon, the unprecedented economic crises and the more recent Beirut port explosion shifted political commitment away from the pandemic, weakening the collaborative and the overall response. In Yemen, the COVID-19 crisis has become yet another politicized element of the ongoing conflict, a way for the opposing parties to point at each other’s failures or even accuse the other of helping spread the virus.

Key reported facilitators

Despite the challenges faced, it is important to note that as a result of the pandemic, progress has been perceived by study participants in the area of multi-sectoral collaboration in the selected countries. When it comes to facilitators, prior relations between sectors and experiences from dealing with previous emerging infectious diseases have been reported. For instance, in the UAE, the pandemic response management was centralized through the pre-existing National Emergency Crisis and Disaster Management Authority (NCEMA), established in 2007. Similarly, the robust preparedness and public health response capabilities in KSA were strengthened by the valuable experience gained from previously managing the Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012 and from decades of planning religious mass gatherings in the face of numerous public health challenges.

Participants also acknowledged the scale and breadth of the COVID-19 pandemic and the urgent need to mitigate its devastating impact, facilitate political commitment and recognize interdependencies over a common threat.

Discussion

Mirroring global efforts, this study demonstrates that the selected nine countries in the EMR are making efforts to incorporate multi-sectoral action into their pandemic responses.

Despite these efforts, persistent challenges and gaps remain, presenting untapped opportunities that can be leveraged for more efficient public health responses in the future. Barriers to multi-sectoral responses were more acute in fragile countries and to a lesser extent in middle-income countries where weak institutions, sectoral bureaucracy and fragmentations have undermined coordination. The most frequently reported barriers across the selected EMR countries were poor multi-sectoral culture; fragmentation of authorities and multiplicity of actors in charge; lack of ownership and mandates specifying roles and responsibilities of different sectors and actors during public health emergencies; competition for resources and lack of mechanisms for conflict management; weak legitimacy of authorities and distrust in government leadership and public institutions; absence of a process to effectively monitor and evaluate the impact of adopted measures and the overall collaborative arrangement; limited resources and funding available for implementing the multi-sectoral response exacerbated by the lack of sustainable joint financing mechanisms; difficulty in sustaining priority for collaboration; and the politicization of the pandemic.

As health challenges increase in complexity, multi-level and multi-disciplinary public health interventions will become the norm [114]. In this regard, it will become increasingly important to capitalize on existing governance functions, institutional structures, mechanisms and partnerships, as well as on research and data ecosystems to reduce duplication of efforts and waste of resources [114]. Governments must continue to build upon the lessons learned from the COVID-19 pandemic to improve and institutionalize multi-sectoral efforts and better be prepared to respond to future crises [91]. Below, we put forward recommendations for strengthening multi-sectoral collaborations for public health emergency responses in the EMR. We also incorporate wider considerations on how the current COVID-19 responses can be used as a window of opportunity to build greater resilience in health systems in the region. The recommendations are grouped into three broad categories: governance and leadership functions; institutional structures, processes and mechanisms; and research and data ecosystems.

At the governance and leadership level, it is critical to ensure a shared understanding and alignment of interests across sectors and actors. Defining a shared vision and agreeing on specific goals are essential for effective and impactful multi-sectoral collaboration [115]. The approach to leadership during public health crises can vary on the basis of the context, governance structures and public health systems of different countries. Centralization and decentralization within and between governments can change in a pandemic; the politics of credit and blame shape politicians’ approaches to problems in complex and context-dependent ways [116]. While there is no one-size-fits-all approach, countries could opt for a hybrid approach, where there is a central coordinating body or leader overseeing the response, but with active involvement and coordination across different sectors at various levels (local, regional and national).

To further enhance collaborative sustainability, leadership capacity needs to be developed across sectors and levels of government, and champions fostered in different sectors that agree on common objectives [117]. Strong coordination is needed to ensure that all sectors are working collaboratively to achieve a whole-of-government, whole-of-society response for addressing national challenges and building resilient health systems [118]. This, in turn, requires a discrete set of governance structures as well as stewardship and leadership skills that broaden collaboration in both horizontal and vertical dimensions [119]. Importantly, there is a need to mobilize and allocate adequate resources for engaging multiple sectors to execute the mandate of the collaboration. Budgeting for collaborative activities should be a joint, multi-sectoral activity [12], and funds should be earmarked (whether through multi-sectoral co-financing, joint funding or new financing solutions) to guarantee the execution of the mandate [120].

At the level of institutional structures, processes and mechanisms, there is a need to create a central coordinating structure that includes representatives from various sectors and actors. While having a multi-sectoral committee is a good start, it does not guarantee success [115]; permanent multi-sectoral structures and mechanisms are preferred for their improved chance of sustainability and longevity; and increased effort should be channelled towards the dynamics of the structure: its mandate, clarity of goals and clarity of roles [8, 115]. Additionally, for collaboration to function effectively, the structure needs to have authority to make decisions and coordinate actions across sectors as well as legitimacy to hold others accountable and manage power conflicts [7]. Importantly, well-implemented communication channels and community engagement processes can support the design of context-specific interventions, build trust in public institutions and provide logistical and administrative support during public health crises [121]. Measurement and evaluation systems can also serve as powerful tools for governing multi-sectoral action [122]. This requires shared indicators that monitor the health, economic and social impacts of the multi-sectoral action, as well as the internal processes and procedures of the collaborative activity [123]. Gathering these data necessitate a shared measurement system involving standardized and ongoing data collection across sectors and actors [123, 124]. There is also a need to reinforce the value of multi-sectoral collaboration, with a focus on competencies for implementing cross-sectoral initiatives.

At the level of research and data ecosystems, governments should strengthen and institutionalize the use of research evidence and public health expertise in decision-making processes. The establishment of a strong evidence base is critical to complement and supplement good governance, fight infodemics and promote trust and accountability [12]. The COVID-19 pandemic can also serve as an impetus to address long-standing underinvestment and undervaluation in health information systems and routine sources of data [125]. Timely data from information and surveillance systems not only informs outbreak response but can also generate much-needed evidence to strengthen the overall health system resilience. Having reliable data can also help set indicators and targets that can be monitored across the collaborative. Finally, it is important to establish transparent mechanisms for coordinating and integrating research, data and expertise across sectors that can enable more effective, efficient and swift responses to increasingly complex public health challenges facing the EMR and the world [77].

Limitations

A limitation of this study is the inclusion of only nine countries from the region; the findings may thus not be generalizable to all EMR context. It is important to scale up the study to other countries in the region. Additionally, while 24 purposively selected stakeholders were initially invited to participate in the key informant interviews, only 8 responded. Nonetheless, these stakeholders represented different sectors including governments, healthcare organizations, non-governmental organizations and academia, which enabled diverse perspectives. In addition, data triangulation helped increase the reliability and validity of findings through cross-checking of information across different data sources. Finally, despite our attempt to conduct a comprehensive search of the literature, we may have missed out on unpublished and not easily accessible data. This is unlikely to significantly change our results.

Conclusions

The COVID-19 pandemic has triggered unprecedented efforts towards multi-sectoral action. Mirroring global efforts, this study demonstrates that the selected nine countries in the EMR are making efforts to integrate multi-sectoral action into their pandemic responses. Nevertheless, persistent challenges and gaps remain, presenting untapped opportunities that governments in the selected EMR countries can leverage to enhance the efficiency of future public health emergency responses. The methodology and framework developed for this study can be replicated in other settings to assess multi-sectoral collaborations and initiatives to respond to public health crises. Study findings can inform multi-sectoral initiatives’ improvement efforts in the EMR and beyond, with a particular emphasis on fragile settings.