an expository essay on controlling covid 19 in nigeria

Why COVID-19 surveillance in Nigeria is critical

• Feinberg School of Medicine
• Global Health

If the United States ignores COVID-19 in Nigeria, we forgo global genomic surveillance at our own peril, reports a new Northwestern Medicine study. 

The study found global efforts to track variants grossly underreported a probable variant of concern, eta, circulating in Nigeria in early 2021. This was followed by the circulation of a rare delta sublineage in the region that was different from the delta variant that circulated in most other parts of the globe.  

“Nigeria is the seventh-most populated country on the planet, but there was very little viral sequencing data available from Nigeria until we started this study,” said co-corresponding study author Judd Hultquist. “The concern in having these gaps in surveillance is there may be new variants popping up in places across the globe we are not seeing. We do not want to be caught unprepared if all of a sudden a new variant with unique properties emerges onto the world stage.”

Hultquist is associate director of the Center for Pathogen Genomics and Microbial Evolution at Northwestern University Feinberg School of Medicine. He also is an assistant professor of medicine in infectious diseases at Feinberg. 

“This study demonstrates the critical need for international cooperation in infectious disease surveillance in undersampled regions for the monitoring and ‘early-warning’ detection of new SARS-CoV-2 variants with concerning potential,” said Ramon Lorenzo-Redondo, co-corresponding study author.

Lorenzo-Redondo is an assistant professor of medicine and the bioinformatics director of the Center for Pathogen Genomics and Microbial Evolution at Feinberg. 

Northwestern scientists sequenced nearly 400 nasal swabs from Nigerian COVID-19 patients, collected by collaborator Dr. Moses Adewumi and his team at the University of Ibadan, who shipped the specimens to Northwestern for sequencing and analysis. The Ibadan scientists did not yet have the equipment or resources to sequence samples at their own institution. 

“What we found was really unexpected,” Hultquist said. 

‘Gaps in surveillance leave us vulnerable’

Northwestern researchers discovered two different variants of the virus that emerged in Nigeria at different times but that went largely underreported.

“We showed one of those variants — now called eta by the World Health Organization — had all the characteristics of a variant of concern,” Hultquist said. “The spike protein of the eta variant was more efficient at promoting infection in vitro and enhanced viral evasion of neutralizing antibody responses following natural infection. Furthermore, eta was able to outcompete the alpha variant in the region before the arrival of delta.

“When alpha was circulating, it was a major focus of concern for public health officials and was widely reported in the media. But eta was more important in Nigeria and other West African countries, even outcompeting alpha in these regions, and we completely missed it. These types of gaps in surveillance leave us vulnerable. How long are we willing to take the risk that an important variant pops up and we miss it until it is already here?”

Several other variants of concern, including beta and omicron, are suspected to have originated from Africa, emphasizing the importance of monitoring these undersampled regions. Scientists in South Africa identified the omicron variant early on and warned it might represent a new variant of concern, enabling other countries to prepare.

“They were absolutely right,” Hultquist said.

The differences in the types of SARS-CoV-2 viruses found in Nigeria compared to the rest of the world suggests there is something about the region that is driving the evolution of these unique variants, which scientists don’t entirely understand. 

Very different viral dynamic is occurring in Nigeria. Why? 

“In this study, we have observed repeated expansions of globally uncommon lineages in Nigeria, which indicates a very different viral dynamic occurring in Nigeria compared to other regions of the world,” Lorenzo-Redondo said.

The country has reported relatively low numbers of hospitalization and low numbers of deaths throughout the pandemic, despite low vaccination rates and a population of over 200 million people. While it’s possible the low case counts and hospitalizations could be due to underreporting, the number of deaths is thought to be more accurate. Part of the explanation for this low mortality rate might be Nigeria’s younger overall population, “but most likely other complex factors not yet understood involving host immunity and/or virus-host interactions are playing a very important role,” Lorenzo-Redondo said. 

“The fact that we have repeatedly seen bizarre variants pop up in Nigeria suggests the virus is there and in high enough numbers to be actively evolving,” Hultquist said. 

To identify what variants might be problematic, scientists rely on how many times they see it and whether it is associated with increases in cases, hospitalizations or deaths. But if a variant pops up in Nigeria where there is little sequencing, scientists might miss early warning signs. By the time it spreads around the globe, it’s too late, Hultquist said. 

“We have to start treating this pandemic truly as a global pandemic,” Hultquist said. “This study demonstrates how our lack of a dedicated, global genomic surveillance effort is resulting in skewed data with potential risks. It’s important to understand what new variants are arising to inform best practices in clinical care and public health policy.” 

Collecting West African samples is currently too arduous

But many low- and middle-income countries need more support. The effort required to obtain the Nigerian samples shows the challenges inherent in these efforts. Researchers in Ibadan had to travel to Lagos, the biggest city in the country, to obtain dry ice, sometimes driving between four and 10 hours in sometimes bad road conditions to do so. After they returned to pack the samples in the ice, they then had to drive again to Lagos to ship them to the U.S. for a total of four often arduous trips. 

Better access to sequencing equipment, supplies and training would allow more of the surveillance to be done in Nigeria. Building capacity for this type of work in other countries remains a major goal for the Center for Pathogen Genomics and Microbial Evolution and Feinberg’s Institute for Global Health.

Research notes

The study was published Feb. 3 in Nature Communications.  It was possible thanks to the long-term collaborative team led by Dr. Babafemi Taiwo, chief of infectious diseases at Feinberg, between Northwestern University and the University of Ibadan.

Other Northwestern authors include Taiwo, Dr. Egon Ozer, Lacy Simons, Taylor Dean and Dr. Mamoudou Maiga.

The research was supported by the Northwestern Havey Institute for Global Health, the Dixon Family Foundation and the Northwestern Center for Advanced Technologies.

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Covid-19 Pandemic, Livelihood and Coping Strategies in Nigeria

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In a few months of COVID-19 pandemic, millions of people were hit by the deadly virus which claimed a lot of lives worldwide, including Nigeria. The Federal Government declared total lockdown of outdoor economic activities, institutions, ceremonies, religious activities and gave a stay at home order to prevent the spread of the deadly virus in the country. This declaration made life difficult for the masses. The livelihood of Nigerians appeared to have been adversely affected by the pandemic. This seemed to make it very hard for people to improve their economic powers. The populace faced challenges in coping with the pandemic in the 36 States of the country. Hence, this paper looked at the concept of COVID-19 pandemic; household livelihoods; challenges from the pandemic; impact of COVID-19 on Girls and Women; copping strategies for the effects of the pandemic. The theory underpinning this study is the motivational instinct theory of survival. The researcher employed secondary data from existing literature from dailies, journals, libraries and text books to source information. The study discovered that the livelihood of people was adversely affected by the circumstances of the pandemic as a result of the hardship caused by government’s restrictions.  Several households relied heavily on government cash relief and food handouts for survival. It was recommended that there should be more intervention strategies for resilience against such shocks in future. Actions should be taken to limit more risk, struggling of households and their livelihoods in urban and rural areas of the country.

Keywords: COVID-19 pandemic , Coping , Livelihood , Strategies. , households

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CDC and Nigeria Respond to COVID-19

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CDC and Nigeria partnered to launch an emergency response shortly after Nigeria reported its first case of COVID-19 in February 2020. Work included scaling up laboratories and supporting emergency operations centers to inform public health efforts and policies to help save lives during the pandemic.

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• Volume 76, Issue 2
• COVID-19 pandemic and its impact on social relationships and health
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• http://orcid.org/0000-0003-1512-4471 Emily Long 1 ,
• Susan Patterson 1 ,
• Karen Maxwell 1 ,
• Carolyn Blake 1 ,
• http://orcid.org/0000-0001-7342-4566 Raquel Bosó Pérez 1 ,
• Ruth Lewis 1 ,
• Mark McCann 1 ,
• Julie Riddell 1 ,
• Kathryn Skivington 1 ,
• Rachel Wilson-Lowe 1 ,
• http://orcid.org/0000-0002-4409-6601 Kirstin R Mitchell 2
• 1 MRC/CSO Social and Public Health Sciences Unit , University of Glasgow , Glasgow , UK
• 2 MRC/CSO Social and Public Health Sciences Unit, Institute of Health & Wellbeing , University of Glasgow , Glasgow , UK
• Correspondence to Dr Emily Long, MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow G3 7HR, UK; emily.long{at}glasgow.ac.uk

This essay examines key aspects of social relationships that were disrupted by the COVID-19 pandemic. It focuses explicitly on relational mechanisms of health and brings together theory and emerging evidence on the effects of the COVID-19 pandemic to make recommendations for future public health policy and recovery. We first provide an overview of the pandemic in the UK context, outlining the nature of the public health response. We then introduce four distinct domains of social relationships: social networks, social support, social interaction and intimacy, highlighting the mechanisms through which the pandemic and associated public health response drastically altered social interactions in each domain. Throughout the essay, the lens of health inequalities, and perspective of relationships as interconnecting elements in a broader system, is used to explore the varying impact of these disruptions. The essay concludes by providing recommendations for longer term recovery ensuring that the social relational cost of COVID-19 is adequately considered in efforts to rebuild.

• inequalities

Data availability statement

Data sharing not applicable as no data sets generated and/or analysed for this study. Data sharing not applicable as no data sets generated or analysed for this essay.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/jech-2021-216690

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Introduction

Infectious disease pandemics, including SARS and COVID-19, demand intrapersonal behaviour change and present highly complex challenges for public health. 1 A pandemic of an airborne infection, spread easily through social contact, assails human relationships by drastically altering the ways through which humans interact. In this essay, we draw on theories of social relationships to examine specific ways in which relational mechanisms key to health and well-being were disrupted by the COVID-19 pandemic. Relational mechanisms refer to the processes between people that lead to change in health outcomes.

At the time of writing, the future surrounding COVID-19 was uncertain. Vaccine programmes were being rolled out in countries that could afford them, but new and more contagious variants of the virus were also being discovered. The recovery journey looked long, with continued disruption to social relationships. The social cost of COVID-19 was only just beginning to emerge, but the mental health impact was already considerable, 2 3 and the inequality of the health burden stark. 4 Knowledge of the epidemiology of COVID-19 accrued rapidly, but evidence of the most effective policy responses remained uncertain.

The initial response to COVID-19 in the UK was reactive and aimed at reducing mortality, with little time to consider the social implications, including for interpersonal and community relationships. The terminology of ‘social distancing’ quickly became entrenched both in public and policy discourse. This equation of physical distance with social distance was regrettable, since only physical proximity causes viral transmission, whereas many forms of social proximity (eg, conversations while walking outdoors) are minimal risk, and are crucial to maintaining relationships supportive of health and well-being.

The aim of this essay is to explore four key relational mechanisms that were impacted by the pandemic and associated restrictions: social networks, social support, social interaction and intimacy. We use relational theories and emerging research on the effects of the COVID-19 pandemic response to make three key recommendations: one regarding public health responses; and two regarding social recovery. Our understanding of these mechanisms stems from a ‘systems’ perspective which casts social relationships as interdependent elements within a connected whole. 5

Social networks

Social networks characterise the individuals and social connections that compose a system (such as a workplace, community or society). Social relationships range from spouses and partners, to coworkers, friends and acquaintances. They vary across many dimensions, including, for example, frequency of contact and emotional closeness. Social networks can be understood both in terms of the individuals and relationships that compose the network, as well as the overall network structure (eg, how many of your friends know each other).

Social networks show a tendency towards homophily, or a phenomenon of associating with individuals who are similar to self. 6 This is particularly true for ‘core’ network ties (eg, close friends), while more distant, sometimes called ‘weak’ ties tend to show more diversity. During the height of COVID-19 restrictions, face-to-face interactions were often reduced to core network members, such as partners, family members or, potentially, live-in roommates; some ‘weak’ ties were lost, and interactions became more limited to those closest. Given that peripheral, weaker social ties provide a diversity of resources, opinions and support, 7 COVID-19 likely resulted in networks that were smaller and more homogenous.

Such changes were not inevitable nor necessarily enduring, since social networks are also adaptive and responsive to change, in that a disruption to usual ways of interacting can be replaced by new ways of engaging (eg, Zoom). Yet, important inequalities exist, wherein networks and individual relationships within networks are not equally able to adapt to such changes. For example, individuals with a large number of newly established relationships (eg, university students) may have struggled to transfer these relationships online, resulting in lost contacts and a heightened risk of social isolation. This is consistent with research suggesting that young adults were the most likely to report a worsening of relationships during COVID-19, whereas older adults were the least likely to report a change. 8

Lastly, social connections give rise to emergent properties of social systems, 9 where a community-level phenomenon develops that cannot be attributed to any one member or portion of the network. For example, local area-based networks emerged due to geographic restrictions (eg, stay-at-home orders), resulting in increases in neighbourly support and local volunteering. 10 In fact, research suggests that relationships with neighbours displayed the largest net gain in ratings of relationship quality compared with a range of relationship types (eg, partner, colleague, friend). 8 Much of this was built from spontaneous individual interactions within local communities, which together contributed to the ‘community spirit’ that many experienced. 11 COVID-19 restrictions thus impacted the personal social networks and the structure of the larger networks within the society.

Social support

Social support, referring to the psychological and material resources provided through social interaction, is a critical mechanism through which social relationships benefit health. In fact, social support has been shown to be one of the most important resilience factors in the aftermath of stressful events. 12 In the context of COVID-19, the usual ways in which individuals interact and obtain social support have been severely disrupted.

One such disruption has been to opportunities for spontaneous social interactions. For example, conversations with colleagues in a break room offer an opportunity for socialising beyond one’s core social network, and these peripheral conversations can provide a form of social support. 13 14 A chance conversation may lead to advice helpful to coping with situations or seeking formal help. Thus, the absence of these spontaneous interactions may mean the reduction of indirect support-seeking opportunities. While direct support-seeking behaviour is more effective at eliciting support, it also requires significantly more effort and may be perceived as forceful and burdensome. 15 The shift to homeworking and closure of community venues reduced the number of opportunities for these spontaneous interactions to occur, and has, second, focused them locally. Consequently, individuals whose core networks are located elsewhere, or who live in communities where spontaneous interaction is less likely, have less opportunity to benefit from spontaneous in-person supportive interactions.

However, alongside this disruption, new opportunities to interact and obtain social support have arisen. The surge in community social support during the initial lockdown mirrored that often seen in response to adverse events (eg, natural disasters 16 ). COVID-19 restrictions that confined individuals to their local area also compelled them to focus their in-person efforts locally. Commentators on the initial lockdown in the UK remarked on extraordinary acts of generosity between individuals who belonged to the same community but were unknown to each other. However, research on adverse events also tells us that such community support is not necessarily maintained in the longer term. 16

Meanwhile, online forms of social support are not bound by geography, thus enabling interactions and social support to be received from a wider network of people. Formal online social support spaces (eg, support groups) existed well before COVID-19, but have vastly increased since. While online interactions can increase perceived social support, it is unclear whether remote communication technologies provide an effective substitute from in-person interaction during periods of social distancing. 17 18 It makes intuitive sense that the usefulness of online social support will vary by the type of support offered, degree of social interaction and ‘online communication skills’ of those taking part. Youth workers, for instance, have struggled to keep vulnerable youth engaged in online youth clubs, 19 despite others finding a positive association between amount of digital technology used by individuals during lockdown and perceived social support. 20 Other research has found that more frequent face-to-face contact and phone/video contact both related to lower levels of depression during the time period of March to August 2020, but the negative effect of a lack of contact was greater for those with higher levels of usual sociability. 21 Relatedly, important inequalities in social support exist, such that individuals who occupy more socially disadvantaged positions in society (eg, low socioeconomic status, older people) tend to have less access to social support, 22 potentially exacerbated by COVID-19.

Social and interactional norms

Interactional norms are key relational mechanisms which build trust, belonging and identity within and across groups in a system. Individuals in groups and societies apply meaning by ‘approving, arranging and redefining’ symbols of interaction. 23 A handshake, for instance, is a powerful symbol of trust and equality. Depending on context, not shaking hands may symbolise a failure to extend friendship, or a failure to reach agreement. The norms governing these symbols represent shared values and identity; and mutual understanding of these symbols enables individuals to achieve orderly interactions, establish supportive relationship accountability and connect socially. 24 25

Physical distancing measures to contain the spread of COVID-19 radically altered these norms of interaction, particularly those used to convey trust, affinity, empathy and respect (eg, hugging, physical comforting). 26 As epidemic waves rose and fell, the work to negotiate these norms required intense cognitive effort; previously taken-for-granted interactions were re-examined, factoring in current restriction levels, own and (assumed) others’ vulnerability and tolerance of risk. This created awkwardness, and uncertainty, for example, around how to bring closure to an in-person interaction or convey warmth. The instability in scripted ways of interacting created particular strain for individuals who already struggled to encode and decode interactions with others (eg, those who are deaf or have autism spectrum disorder); difficulties often intensified by mask wearing. 27

Large social gatherings—for example, weddings, school assemblies, sporting events—also present key opportunities for affirming and assimilating interactional norms, building cohesion and shared identity and facilitating cooperation across social groups. 28 Online ‘equivalents’ do not easily support ‘social-bonding’ activities such as singing and dancing, and rarely enable chance/spontaneous one-on-one conversations with peripheral/weaker network ties (see the Social networks section) which can help strengthen bonds across a larger network. The loss of large gatherings to celebrate rites of passage (eg, bar mitzvah, weddings) has additional relational costs since these events are performed by and for communities to reinforce belonging, and to assist in transitioning to new phases of life. 29 The loss of interaction with diverse others via community and large group gatherings also reduces intergroup contact, which may then tend towards more prejudiced outgroup attitudes. While online interaction can go some way to mimicking these interaction norms, there are key differences. A sense of anonymity, and lack of in-person emotional cues, tends to support norms of polarisation and aggression in expressing differences of opinion online. And while online platforms have potential to provide intergroup contact, the tendency of much social media to form homogeneous ‘echo chambers’ can serve to further reduce intergroup contact. 30 31

Intimacy relates to the feeling of emotional connection and closeness with other human beings. Emotional connection, through romantic, friendship or familial relationships, fulfils a basic human need 32 and strongly benefits health, including reduced stress levels, improved mental health, lowered blood pressure and reduced risk of heart disease. 32 33 Intimacy can be fostered through familiarity, feeling understood and feeling accepted by close others. 34

Intimacy via companionship and closeness is fundamental to mental well-being. Positively, the COVID-19 pandemic has offered opportunities for individuals to (re)connect and (re)strengthen close relationships within their household via quality time together, following closure of many usual external social activities. Research suggests that the first full UK lockdown period led to a net gain in the quality of steady relationships at a population level, 35 but amplified existing inequalities in relationship quality. 35 36 For some in single-person households, the absence of a companion became more conspicuous, leading to feelings of loneliness and lower mental well-being. 37 38 Additional pandemic-related relational strain 39 40 resulted, for some, in the initiation or intensification of domestic abuse. 41 42

Physical touch is another key aspect of intimacy, a fundamental human need crucial in maintaining and developing intimacy within close relationships. 34 Restrictions on social interactions severely restricted the number and range of people with whom physical affection was possible. The reduction in opportunity to give and receive affectionate physical touch was not experienced equally. Many of those living alone found themselves completely without physical contact for extended periods. The deprivation of physical touch is evidenced to take a heavy emotional toll. 43 Even in future, once physical expressions of affection can resume, new levels of anxiety over germs may introduce hesitancy into previously fluent blending of physical and verbal intimate social connections. 44

The pandemic also led to shifts in practices and norms around sexual relationship building and maintenance, as individuals adapted and sought alternative ways of enacting sexual intimacy. This too is important, given that intimate sexual activity has known benefits for health. 45 46 Given that social restrictions hinged on reducing household mixing, possibilities for partnered sexual activity were primarily guided by living arrangements. While those in cohabiting relationships could potentially continue as before, those who were single or in non-cohabiting relationships generally had restricted opportunities to maintain their sexual relationships. Pornography consumption and digital partners were reported to increase since lockdown. 47 However, online interactions are qualitatively different from in-person interactions and do not provide the same opportunities for physical intimacy.

Recommendations and conclusions

In the sections above we have outlined the ways in which COVID-19 has impacted social relationships, showing how relational mechanisms key to health have been undermined. While some of the damage might well self-repair after the pandemic, there are opportunities inherent in deliberative efforts to build back in ways that facilitate greater resilience in social and community relationships. We conclude by making three recommendations: one regarding public health responses to the pandemic; and two regarding social recovery.

Recommendation 1: explicitly count the relational cost of public health policies to control the pandemic

Effective handling of a pandemic recognises that social, economic and health concerns are intricately interwoven. It is clear that future research and policy attention must focus on the social consequences. As described above, policies which restrict physical mixing across households carry heavy and unequal relational costs. These include for individuals (eg, loss of intimate touch), dyads (eg, loss of warmth, comfort), networks (eg, restricted access to support) and communities (eg, loss of cohesion and identity). Such costs—and their unequal impact—should not be ignored in short-term efforts to control an epidemic. Some public health responses—restrictions on international holiday travel and highly efficient test and trace systems—have relatively small relational costs and should be prioritised. At a national level, an earlier move to proportionate restrictions, and investment in effective test and trace systems, may help prevent escalation of spread to the point where a national lockdown or tight restrictions became an inevitability. Where policies with relational costs are unavoidable, close attention should be paid to the unequal relational impact for those whose personal circumstances differ from normative assumptions of two adult families. This includes consideration of whether expectations are fair (eg, for those who live alone), whether restrictions on social events are equitable across age group, religious/ethnic groupings and social class, and also to ensure that the language promoted by such policies (eg, households; families) is not exclusionary. 48 49 Forethought to unequal impacts on social relationships should thus be integral to the work of epidemic preparedness teams.

Recommendation 2: intelligently balance online and offline ways of relating

A key ingredient for well-being is ‘getting together’ in a physical sense. This is fundamental to a human need for intimate touch, physical comfort, reinforcing interactional norms and providing practical support. Emerging evidence suggests that online ways of relating cannot simply replace physical interactions. But online interaction has many benefits and for some it offers connections that did not exist previously. In particular, online platforms provide new forms of support for those unable to access offline services because of mobility issues (eg, older people) or because they are geographically isolated from their support community (eg, lesbian, gay, bisexual, transgender and queer (LGBTQ) youth). Ultimately, multiple forms of online and offline social interactions are required to meet the needs of varying groups of people (eg, LGBTQ, older people). Future research and practice should aim to establish ways of using offline and online support in complementary and even synergistic ways, rather than veering between them as social restrictions expand and contract. Intelligent balancing of online and offline ways of relating also pertains to future policies on home and flexible working. A decision to switch to wholesale or obligatory homeworking should consider the risk to relational ‘group properties’ of the workplace community and their impact on employees’ well-being, focusing in particular on unequal impacts (eg, new vs established employees). Intelligent blending of online and in-person working is required to achieve flexibility while also nurturing supportive networks at work. Intelligent balance also implies strategies to build digital literacy and minimise digital exclusion, as well as coproducing solutions with intended beneficiaries.

Recommendation 3: build stronger and sustainable localised communities

In balancing offline and online ways of interacting, there is opportunity to capitalise on the potential for more localised, coherent communities due to scaled-down travel, homeworking and local focus that will ideally continue after restrictions end. There are potential economic benefits after the pandemic, such as increased trade as home workers use local resources (eg, coffee shops), but also relational benefits from stronger relationships around the orbit of the home and neighbourhood. Experience from previous crises shows that community volunteer efforts generated early on will wane over time in the absence of deliberate work to maintain them. Adequately funded partnerships between local government, third sector and community groups are required to sustain community assets that began as a direct response to the pandemic. Such partnerships could work to secure green spaces and indoor (non-commercial) meeting spaces that promote community interaction. Green spaces in particular provide a triple benefit in encouraging physical activity and mental health, as well as facilitating social bonding. 50 In building local communities, small community networks—that allow for diversity and break down ingroup/outgroup views—may be more helpful than the concept of ‘support bubbles’, which are exclusionary and less sustainable in the longer term. Rigorously designed intervention and evaluation—taking a systems approach—will be crucial in ensuring scale-up and sustainability.

The dramatic change to social interaction necessitated by efforts to control the spread of COVID-19 created stark challenges but also opportunities. Our essay highlights opportunities for learning, both to ensure the equity and humanity of physical restrictions, and to sustain the salutogenic effects of social relationships going forward. The starting point for capitalising on this learning is recognition of the disruption to relational mechanisms as a key part of the socioeconomic and health impact of the pandemic. In recovery planning, a general rule is that what is good for decreasing health inequalities (such as expanding social protection and public services and pursuing green inclusive growth strategies) 4 will also benefit relationships and safeguard relational mechanisms for future generations. Putting this into action will require political will.

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Twitter @karenmaxSPHSU, @Mark_McCann, @Rwilsonlowe, @KMitchinGlasgow

Contributors EL and KM led on the manuscript conceptualisation, review and editing. SP, KM, CB, RBP, RL, MM, JR, KS and RW-L contributed to drafting and revising the article. All authors assisted in revising the final draft.

Funding The research reported in this publication was supported by the Medical Research Council (MC_UU_00022/1, MC_UU_00022/3) and the Chief Scientist Office (SPHSU11, SPHSU14). EL is also supported by MRC Skills Development Fellowship Award (MR/S015078/1). KS and MM are also supported by a Medical Research Council Strategic Award (MC_PC_13027).

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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• Published: 08 May 2023

COVID-19 surveillance in Democratic Republic of Congo, Nigeria, Senegal and Uganda: strengths, weaknesses and key Lessons

• Olufunmilayo Ibitola Fawole 1   na1 ,
• Segun Bello 1   na1 ,
• Ayo Stephen Adebowale 1 ,
• Eniola Adetola Bamgboye 1 ,
• Mobolaji Modinat Salawu 1 ,
• Rotimi Felix Afolabi 1 ,
• Magbagbeola David Dairo 1 ,
• Alice Namale 2 ,
• Suzanne Kiwanuka 2 ,
• Fred Monje 2 ,
• Noel Namuhani 2 ,
• Steven Kabwama 2 ,
• Susan Kizito 2 ,
• Rawlance Ndejjo 2 ,
• Ibrahima Seck 3 ,
• Issakha Diallo 3 ,
• Mamadou Makhtar 3 ,
• Mbacke Leye 3 ,
• Youssou Ndiaye 3 ,
• Manel Fall 3 ,
• Oumar Bassoum 3 ,
• Mala Ali Mapatano 4 ,
• Marc Bosonkie 4 ,
• Landry Egbende 4 ,
• Siobhan Lazenby 5 ,
• William Wang 5 ,
• Anne Liu 5 ,
• Rebecca Bartlein 5 ,
• William Sambisa 6 &
• Rhoda Wanyenze 2  

BMC Public Health volume  23 , Article number:  835 ( 2023 ) Cite this article

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Introduction

As part of efforts to rapidly identify and care for individuals with COVID-19, trace and quarantine contacts, and monitor disease trends over time, most African countries implemented interventions to strengthen their existing disease surveillance systems. This research describes the strengths, weaknesses and lessons learnt from the COVID-19 surveillance strategies implemented in four African countries to inform the enhancement of surveillance systems for future epidemics on the continent.

The four countries namely the Democratic Republic of Congo (DRC), Nigeria, Senegal, and Uganda, were selected based on their variability in COVID-19 response and representation of Francophone and Anglophone countries. A mixed-methods observational study was conducted including desk review and key informant interviews, to document best practices, gaps, and innovations in surveillance at the national, sub-national, health facilities, and community levels, and these learnings were synthesized across the countries.

Surveillance approaches across countries included - case investigation, contact tracing, community-based, laboratory-based sentinel, serological, telephone hotlines, and genomic sequencing surveillance. As the COVID-19 pandemic progressed, the health systems moved from aggressive testing and contact tracing to detect virus and triage individual contacts into quarantine and confirmed cases, isolation and clinical care. Surveillance, including case definitions, changed from contact tracing of all contacts of confirmed cases to only symptomatic contacts and travelers. All countries reported inadequate staffing, staff capacity gaps and lack of full integration of data sources. All four countries under study improved data management and surveillance capacity by training health workers and increasing resources for laboratories, but the disease burden was under-detected. Decentralizing surveillance to enable swifter implementation of targeted public health measures at the subnational level was a challenge. There were also gaps in genomic and postmortem surveillance including community level sero-prevalence studies, as well as digital technologies to provide more timely and accurate surveillance data.

All the four countries demonstrated a prompt public health surveillance response and adopted similar approaches to surveillance with some adaptations as the pandemic progresses. There is need for investments to enhance surveillance approaches and systems including decentralizing surveillance to the subnational and community levels, strengthening capabilities for genomic surveillance and use of digital technologies, among others. Investing in health worker capacity, ensuring data quality and availability and improving ability to transmit surveillance data between and across multiple levels of the health care system is also critical. Countries need to take immediate action in strengthening their surveillance systems to better prepare for the next major disease outbreak and pandemic.

Peer Review reports

The Coronavirus disease of 2019 (COVID-19) was first reported in Wuhan city of the Hubei Province in China around late December 2019 [ 1 ]. On 30th of January 2020, the World Health Organisation (WHO) declared COVID-19 a Public Health Emergency of International Concern [ 2 ]. COVID-19 was declared a pandemic on 11th of March 2020 and by the 23rd of February, 2023, it had caused over 757 million confirmed cases and over 6.8 million deaths globally [ 3 ].

Nigeria was one of the first countries in Africa to report a case of COVID-19 on 27th of February, 2020 [ 4 ]. A few days later, on 2nd of March, Senegal reported its first case in a traveler arriving from France [ 5 ]. Uganda and the Democratic Republic of Congo (DRC) also reported cases in March 2020 [ 6 ]. Like many other African countries, these four countries experienced a relatively mild first wave of the pandemic (through July 2020) reporting a total of 17998, 35511, 87564, and 19140 for DRC, Uganda, Nigeria and Senegal, respectively [ 7 ]. The period for subsequent waves of infection differed slightly between countries. A second wave of cases and deaths followed between November 2020 and February 2021, except in the DRC where the reported burden remained low. In early June 2021, Senegal had the most reported cases and death per capita. By the middle of June through July 2021, Uganda had already overtaken Senegal and peaked in a third wave while Senegal was already experiencing a trough.

Surveillance is one of the most critical features of disease outbreak detection and pandemic response [ 8 , 9 ]. The objectives of COVID-19 surveillance are to: enable the rapid detection, isolation, and management of suspected and probable cases including detecting and containing the clusters and outbreaks, especially among vulnerable populations [ 10 ]. Furthermore, surveillance is key to identifying, following up with, and quarantining contacts of confirmed COVID-19 cases at the beginning of the pandemic and providing requisite data to guide the implementation and adjustment of targeted control measures [ 10 ].

Compared with the rest of the world, COVID-19 has not been as severe in Africa. Although the African continent is home to about 14 per cent of the world’s population, the region has accounted for only about 2 per cent of reported cases and deaths as at 10th November, 2020 [ 11 ]. Low case detection rates and reporting gaps exist in COVID-19 cases and deaths across the world, and these are particularly acute in sub-Saharan Africa (SSA) [ 12 ] due to weakeness of infectious disease and mortality surveillance systems. Disease reporting gaps could partially explain the relatively lower COVID-19 burden in SSA [ 13 , 14 ]. Test positivity, or the proportion of COVID-19 tests that are positive, can be used as a marker of how widespread the infection is and whether sufficient testing is being done. WHO suggests that a positivity rate of less than 5 percent is one indicator that a country has the spread of COVID-19 under control [ 15 ]. During some phases of the pandemic, especially during the second wave between November 2020 and February 2021, the test-positivity rates in all four countries were greater than 10 percent, much higher than the WHO benchmark of 5 percent, [ 16 ] suggesting a substantial undetected burden of COVID-19 by the surveillance systems.

To inform the development of sustainable and resilient surveillance systems for current COVID-19 response efforts and future disease preparedness in the region and globally, this study aimed to analyse and document the surveillance strategies in response to the COVID-19 pandemic adopted by four countries in SSA namely, the DRC, Nigeria, Senegal and Uganda.

Methodology

Study setting.

The study was conducted in the DRC, Nigeria, Senegal and Uganda. These four countries were selected for the following reasons:

Variation in their COVID-19 responses, in terms of the scope and intensity of non-pharmaceutical interventions and their intended outcomes [ 17 ].

Historical experience in managing epidemics of global concern, such as yellow fever, Ebola virus disease, and Marburg virus disease [ 18 , 19 , 20 ].

Existing partnerships between local research institutions and government departments for ease of implementation and translation of research findings to evidence-based policy and practices.

Mixture of Francophone (the DRC and Senegal) and Anglophone (Nigeria and Uganda) [ 21 ] countries to enhance South-to-South cross-learning.

Study design

This study used a mixed-methods observational approach based on the surveillance and public health action framework (Fig.  1 ). The mixed-methods consisted of; 1) a desk review of the literature and relevant documents, and 2) key informant interviews (KIIs). First, the study undertook reviews of each country’s guidelines and response plans, response reports, websites, presentations, and analysis of the COVID-19 epidemic curve. Second, researchers from the four countries conducted KIIs to further explore the issues identified in the desk reviews. Promising practices, innovations, and challenges with key recommendations for moving forward were documented and presented in this paper.

Testing, Surveillance and Public Health Action Framework

Source: Exemplars in Global Health, 2021

The surveillance and public health action framework has the following five (5) domains each having at least two components: Response Strategy, Testing, Surveillance and Data Analysis, Public Health Action and Coordination, (Fig.  1 ).First, the Response Strategy domain includes setting testing and surveillance procedures and goals, partly informed by the ‘’pre-pandemic context, including exposure to prior epidemics [ 21 ]. Second, the Testing domain has one component titled use of diagnostic tests (e.g., RT-PCR) to identify COVID-19 cases which has several sub-components namely production and sourcing, test delivery, sample collection and test demand, sample delivery, laboratory analysis, and result communication [ 21 ]. Third, the Surveillance and Data Analysis domain constitutes of the following two components, namely collection, analysis and use of data to identify and understand trends in the outbreak (e.g., identification of case clusters) and use of different surveillance modalities (e.g.,, serological surveys, mortality surveillance). Then the Public Health Action domain constitutes four components namely setting new priorities and policies for response, case management for known and suspected cases, establishing guidelines for contact tracing and quarantine, and investigation and control measures. Finally, the Coordination domain constitutes two components which are establishing task forces groups and committees to manage aspects of direct surveillance and testing activities, and establishing regulatory practices [ 21 ]. This study focuses on only the surveillance and does not explore aspects of testing which is being addressed in another publication [ 21 ]. The study also explores how other components such as response strategy, public health action and coordination influence surveillance and data analysis.

Study population

Study participants were selected based on their role in the COVID-19 response. They typical include policy makers and members of the national and regional emergency operations centres for COVID-19 response. Informants were identified and selected from national public health institutes, Nigeria centre for disease control, state ministry of health and local/district health authority. Research assistants visited the offices offices of the informants at their convenient time to conduct the KIIs. The study conducted (KIIs) with 30 informants per country, including policy makers, epidemic focal persons, and health managers.

Study instrument

Two data collection instruments were used (Supplementary Materials). The first instrument was a literature abstraction form (Additional file 1) used to gather information across the four countries on testing modalities, changes in testing criteria, modalities of implementing contact tracing, isolation, screening and the surveillance modalities for COVID-19. The second instrument was a KII guide (Additional file 2) which was used to obtain information on the strengths and weaknesses of the surveillance strategies in the four countries. The KII themes under which information was gathered were past experience with epidemics, health system preparedness (specifically about funding), response to the COVID-19 pandemic in Africa and the outcomes in terms of non-pharmaceutical COVID-19 control strategies, including strategies to ensure continuity of essential non-COVID services.

Data collection

The data extraction form was developed and piloted in the excel format but was also applied in the word document format to extract data, depending on preference by country teams. The sections relevant to surveillance extracted data on strategies including; modalities of contact tracing, modality of implementing isolation, modalities of screening, and surveillance data. For each strategy, data on key strengths, weaknesses, challenges and gaps were also extracted where reported. Investigators conducted search and extracted data on different sections independently.

In each country, data collection was facilitated by skilled research assistants with proficiency in qualitative research. The research assistants received additional training on data collection strategies and use of the guide. Between February and March, 2021, 30 KII were conducted in English (Nigeria and Uganda) and French (the DRC and Senegal) among policy makers, program managers, and epidemic response and health system implementers and managers to further explore the issues identified in the desk research.

Prior to conducting the KIIs, the research team conducted a desk research. The mixed-methods observational approach was utilized to facilitate the triangulation of information to enable a wide-ranging documentation of the strengths, weaknesses, gaps and innovations in surveillance at the national, sub-national, health facilities, implementing partners and community levels. Key learnings both similar and unique to a specific country context were synthesized across the countries.

Data management

The data from the literature review were synthesized thematically. All KIIs were audio-recorded on mobile phones and voice recorders. Codes were assigned to each key informant to ensure the confidentiality of the participants. The recorded data were transcribed, cleaned and coded. Thematic analysis was done using Excel and Atlas Ti software packages. The recordings and notebooks were securely stored in locked cabinets and password protected.

Ethical considerations

Each country research team obtained ethical clearance from relevant national and Institutional Review Boards. Clearance was obtained as such DRC- No d’Approbation: ESP/CE/198/2020; Nigeria-NHREC/01/01/2007; Senegal-000279/MSAS/DPRS/DR 03/03/2021; and Uganda-UNCST HS 1121ES/HDREC 903. The study was conducted in accordance with the Declaration of Helsinki. The permission of the gatekeepers’ was obtained to allow access to the facilities. Before conducting interviews, the purpose of the study was explained to the participants who provided written or verbal (for respondents who desired more anonymity) informed consent depending on the country. Importantly, participants were reassured of confidentiality of their responses and anonymity.

Literature review

All four countries are committed to the Global Health Security Agenda (GHSA), and the International Health Regulations 2005. Furthermore, they all are implementing the Integrated Disease Surveillance and Response [ 21 ] system [ 22 ]. Table  1 shows the pre-pandemic health context in the four countries. Nigeria is the most populous of the four countries (215 million) compared to Senegal’s 17 million. On the other hand, Senegal had the highest life-expectancy of 68.5 years while Nigeria has the lowest at 54.3 years. Uganda has the best universal health care coverage index of 53 compared to the + DRCs 45 [ 23 , 24 ]. Prior to the COVID-19 pandemic, WHO and MOH collaborative evalutions found that all four countries had very limited capacity in the following technical area across all levels of the epidemic preparedness of the health system namely detection, response and control of public health threats (WHO JEE reports: DRC-2018; Nigeria-2017; Senegal-2016; Uganda-2017). The COVID-19 epidemic underscored the critical role of surveillance in protecting individual nations and the global community.

Surveillance for COVID-19 was risk-based across all four countries and the prevention, control and mitigation strategies implemented had many similarities. Initially, the priority groups for contact tracing were all contacts of confirmed cases, travelers originating from countries that had reported COVID-19 cases, and health care workers exposed to confirmed cases, but as the pandemic progressed the prioritization was revised to include only symptomatic contacts and travelers. To implement contact tracing, additional human resources were engaged either through recruitment of volunteers or contract staff. Initially, contact tracing was centrally coordinated and targeted all contacts, but as the epidemic progressed to widespread community transmission and the cases increased, the activity was decentralized and tracing targeted individuals at higher risk of severe disease. Effectiveness of contact tracing during early phases was generally good, with over 90% of contacts reportedly traced in all the countries [ 25 ].

Morbidity and mortality due to COVID-19

Table  2 shows data from literature on the morbidity and mortality patterns due to COVID-19 in the four countries under study. As at April 2022, Senegal had the highest number of cases and deaths per million and the DRC had the least (5000 and 114.27 versus 939.05 and 14.47 per million respectively).

Synthesis of literature review and key informant interviews

Surveillance methods and systems.

Across the study sites and contexts, a networked and combination of different surveillance methods were used to get a holistic picture of the spread of the COVID-19 disease and behavior of the populations served by ministries of health and donors. The examples of methods used across the four countries can be classified into active and passive surveillance. The active surveillance included case investigation, contact tracing, community-based surveillance, sentinel site surveillance, serological survey, event-based surveillance, telephone hotlines, genomic sequencing and pathogen surveillance and environmental surveillance. The passive surveillance included surveillance at the primary care level, laboratory-based surveillance, hospital/facility-based surveillance, point of entry surveillance, work-based surveillance, mortality and postmortem surveillance. These surveillance systems have been linked to electronic data collection and reporting systems e.g. District Health Information Sysytem (DHIS-2) and Surveillance Outnreak Response Managaement and Analysis System (SORMAS) for real time access. Findings from the KIIs also buttressed the adoption and use of these various methods. Active case findings were adopted in community based surveillance across countries such as Nigeria, Uganda and DRC. Community health workers and village health teams collaborated with community members in some instances for community ownership of the tracing process. One key informant noted that:

“Community health workers conducted community surveillance through active case searches as well as the national COVID-19 hotline, which managed nearly 3,000 calls per day by November 2020. Community health workers also were involved in contact tracing and supported outreach in each health zone” ( MoH, Epidemiological Surveillance Directorate, DRC) Networks of laboratories coordinated and funded by the government and partners such as the CDC Atlanta, were set up and connected across regions of the countries for laboratory-based surveillance. These laboratories as well as facilities involved in facility-based surveillance were linked to SORMAS for reporting as mentioned by a respondent: “We set up laboratories almost all over the state in Nigeria and this all pulled down to the hub, the national reference laboratory situated at Gaduwa in Abuja. And this also helped to ensure testing and ensure that the laboratory-based surveillance is been done for COVID-19” (Case Management Pillar Member NC, Nigeria) “Facility based surveillance was done to obtain information from people in the hospitals. The data was included into SORMAS, and that was where we got some information for trend, transmission peculiar to Nigeria unlike the other parts of the world, assessment, demographic figures concerning COVID-19. We discovered that COVID cut across all ages, even newborns tested positive. It is also the same risk for men and women, but more in men. All these information peculiars to our environment were derived from our own data” (Laboratory Team Lead, State Emergency Operations Centre [EOC], SW Nigeria.)

Across countries under review, air, land and maritime borders were subjected to point of entry surveillance. Trained personnel were deployed to screen travelers and contacts of suspected cases. A key informant from Senegal described this:

“surveillance has always been daily but it has been reinforced with the arrival of this pandemic... surveillance has been reinforced, particularly at the border level because there is a flow of travelers which means that the risks were as much as possible, particularly at the level of air borders, but we have also not forgotten the surveillance of maritime and land borders...“ (Technical Manager at MoHSA-Senegal)

Furthermore, work-based surveillance was instituted in most work places with preventive instructions such as staff being instructed to work from or stay at home when ill as described by a key informant:

“Well... work-based surveillance was basically introduced through Infection Prevention and Control (IPC) [ 26 ]. So, IPC people were trained on how to identify these cases. First of all, surveillance is basically about identifying a case and reporting. That’s surveillance. Seeing and knowing institutions that this it is. So in offices, people who were seen to have had respiratory illnesses were asked to stay at home, get tested and come back to work when they are well. So, that was the form of surveillance that was done (Surveillance Officer, Uganda)

Mortality and postmortem COVID-19 surveillance was implemented to prevent infection to bereaved families during preparation for burial for the deceased because of delayed test results as indicated by a key informant:

“We had some cases that their sample were taken for investigation. Some people tested positive after death. Other things might have killed the patients, but we were able to confirm COVID-19” (Laboratory Team Lead, State Emergency Operation Centre (EOC), SW Nigeria)

Sentinel site surveillance. Population-based surveys of antibody sero-positivity and the use of serology in specific settings or populations to estimate the proportion of the population that had been infected with SARS-CoV-2 were done by all. Uganda conducted three community surveys and testing for COVID-19, twice in 2020 and once in March 2021, to determine the community burden to complement the surveillance efforts. Also, Nigeria conducted a national serological survey (September-October 2020 that found up to 23% in Lagos had COVID-19 antibodies, much higher than expected [ 12 ]. Later, another survey was conducted in May-June 2021 with report which is not yet in public domain. In June 2020, the DRC conducted ‘mass’ COVID-19 testing in one section of the capital city, Kinshasa, the epicenter of COVID-19. On the other hand, Senegal conducted a national survey in October, 2020. Figures  2 and 3 show the daily new confirmed COVID-19 cases per million people and the proportion of COVID-19 tests that are positive, respectively.

Daily new confirmed COVID_19 cases per million

The share of COVID_19 test that are positive

Key strengths of the surveillance approaches employed

Table  3 below describes key strengths and challenges of the surveillance system that were observed in the study countries.

Leveraging pre-existing surveillance systems for COVID-19 surveillance. All four study countries had existing functional surveillance systems networked with national laboratories as well as have trained and experienced surveillance teams with in-country epidemiologists capacities [ 27 , 28 ]. The previous disease outbreak experiences contributed to rapid preparedness planning for COVID-19 and use of the existing surveillance capacities and capabilities. For example, during the oubreak of COVID-19, the DRC had an ongoing Ebola epidemic and had trained and mobilized surveillance officers while Uganda’s community surveillance officers had been recently trained in preparation of possible cross-border transmission of the DRC Ebola outbreak (2018–2020). These active and preparatory capacities for the Ebola outbreak were immediately available to support COVID-19 surveillance. Previous experiences with similar outbreaks helped the two countries to rapidly ramp up surveillance capacity [ 12 , 29 ]. Similarly, Senegal and Nigeria had experienced previous Ebola disease outbreaks and established relevant surveillance systems.

“For the experience we have gained in the management of previous epidemics, it is important to know that Senegal is not at its first epidemic, we have had to manage a lot of epidemics…take as an example the Ebola virus disease even if we had only one case it is this epidemic experience allowed us to strengthen our system and it is precisely after this epidemic that the COUS Health Emergency Operations Center was created with the main mission of preparing the response to the public health emergency” – (Member of the Emergency Operation Center , Senegal)

Capacity enhancement .All the four participating countries strengthened surveillance capacity at sub-national level by training rapid response teams at district/regional/provincial/state levels, with support from development partners [ 30 ]. Sub-national teams were pivotal in supporting lower-level structures including community health workers to conduct contact tracing. Training, dissemination of policies and tools (i.e., data collection forms, case definitions, and reporting tools) to support surveillance occurred in a timely manner. However, all four countries reported staffing shortages especially for dedicated surveillance officers at the local levels of the operation of the surveillance systems.

‘’Not only Village Health Teams (VHTs) but we also brought the community leaders on board to do surveillance, and that is working for us very well…the community is leading the surveillance rather than for us [ 31 ] owning the activity”( District Surveillance Focal Person, Uganda )

“In Uganda the use of community health workers to implement COVID-19 surveillance was a strength, while in DRC, the use of Early Warning, Alert and Response System (EWARS) (Early Warning, Alert and Response System) was a strength” (Surveillance officer, DRC )

Data management reporting and use : All the four countries had established databases with capacity to report on key indicators on the status of the response to COVID-19. These countries built the reporting of COVID-19 indicators on existing data management systems for collecting, collating, analysis and reporting on the performance of these indicators. All countries adopted electronic systems to improve timeliness of reporting. The reporting systems were linked to the current (DHIS-2) system which enhanced storage, retrieval, analysis, and presentation as well as interpolation with existing data. Data was shared through dashboards [ 32 ], bulletins, situation reports and was accessible to key decision makers to support the response. The availability of scientifically sound data contributed to the regular review and update of surveillance policies and strategies. The use of digital platforms, short text messages and telephone calls was reported by all countries for sharing results with decision-makers and for improving the health of the population in their jurisdiction. However, interoperability and data quality were still key challenges.

“To the best of my knowledge I will say [SORMAS] is near perfect…because we are not using the outdated paper-based surveillance system, we are using the e-format…which is like ‘real time’, because as soon as the result is received from the lab, the data manager inputs the results electronically, and at that point everybody who is a stakeholder sees it and can respond” ( Capacity Building Trainer, NC, Nigeria ).

“In June 2020, with technical assistance from the health systems firm Bluesquare, some health zones piloted digital reporting to replace the paper-based reporting in use under the Integrated Disease Surveillance and Response strategy. The objective was to incorporate COVID-19 indicators into DHIS2 and improve the timeliness of case reporting. In addition, WHO started piloting the Early Warning, Alert and Response System (EWARS) in some health zones. However, as of December 2020, the Bluesquare and WHO systems were not fully integrated” ( MoH, Epidemiological Surveillance Directorate, DRC )

“ The tracker is a module that has been developed, and which makes it possible to follow all the cases as well as their contacts” ( DHIS manager-Senegal)

Multisectoral engagement and partnerships: Each country established or leveraged robust partnerships with non-governmental organizations, academics, and other global institutions.

Key challenges and gaps

The following challenges with the surveillance systems were observed in the four study countries [ 26 ]:-.

Inadequate human resources - The four countries lacked adequate human resources to trace contacts, in addition to testing and insufficient space for institutional quarantine and isolation for individuals tested as COVID-19 positive. For example, in Uganda the shortage of surveillance officers at the facilities affected contact tracing and other public health actions. The lack of appropriately trained human resource was more prominent at the lower levels. Similar challenges were reported in the DRC, Senegal and Nigeria.

“Yea, some of the gaps are in terms of the level of human resources, because whether we like it or not even though the response is being coordinated at the National level it still needs to get them to the sub-national level. So, there are issues of inadequate human resources and also financial resources too. Response required a lot of resources that were not available” (Case Management Pillar Member, National EOC, FCT, Nigeria)

Low case detection rates - In the later phases of the pandemic, COVID-19 case detection was suboptimal because of limited capacity in terms of testing and workforce, and as a result of the shift to the risk-based testing strategy that the four countries adopted. The serological survey conducted in Nigeria confirmed that infection rates were over 20% and much higher than reported. In Uganda, the reported ‘probable deaths’ were comparable to the confirmed deaths which suggested under testing and underreporting of cases and deaths. Furthermore, there was underreporting of cases in both the DRC and Uganda.

“The current epidemiological situation is only the tip of the iceberg. A large part of the cases is not detected” ( Member, Presidential Committee for Epidemiological Surveillance, DRC ).

“In the early part of this outbreak, everyone was reporting COVID-19 and it was difficult and expensive for us to do verification therefore, we missed cases” ( Regional surveillance focal person, Uganda )

“ Many people were hiding and did not want to admit they had COVID because they did not believe that the existed, this meant that cases that were probably and died in the community without being detected. Thus, a large number of deaths in community escaped the vigilance of epidemiological surveillance ” (Member, National Committee for Epidemiological Surveillance, DRC).

Limited genetic sequencing - The surge in cases through December 2020 was reported to be due to coronavirus variants with increased transmissibility [ 33 ]. However, the four countries had limited capacities for routine genotype tracking of the transmission dynamics and for planning. For example, in the identification of effective vaccines, it is important to know the circulating virus strains. Senegal and Nigeria had both reported presence of Omicron (November/December, 2021) and Delta (July 2021) mutant variants in the population while DRC identified omicron variant in December 2021. The omicron variant coincided with the resurgence of seasonal influenza, which has some symptoms similar to those of COVID-19, including prolonged cough, fever, headache, fatigue, body aches, weakness while Uganda identified first case of omicron by December, 2021 [ 34 ].

Decentralized surveillance capacity was generally weak - In Uganda, all the districts could not implement surveillance activities without support from the national level. Nigeria reported the State EOCs were weak and not routinely using the available data.

“For COVID-19 surveillance to be improved, part of what I think the country can do more is that to make sure that interface between SORMAS and other system that are being use by parastatals are made seamless and to encourage more states to key to the SORMAS system, to make sure that there are more trainings, which they have being doing, with key stakeholders, surveillance leads or surveillance department team in every state of the Federation ” (Case Manager, State EOC, NC, Nigeria)

“Uganda experienced challenges with response at the EOC and were overwhelmed with the COVID-19 cases. “We lost time until a point of inefficiency when many calls overwhelmed the EOC call center where some were not being picked or attended to, until we decentralized” ( Surveillance Officer, Uganda )

Insufficient space for quarantine and isolation - In all four countries, there was insufficient accommodation space for quarantine and isolation. For example, at the beginning of the COVID-19 response in Nigeria, quarantine and isolation was carried out in government approved hotels, and in some instances all confirmed cases where hospitalized irrespective of disease severity. Initially the governments paid for hotel accommodation and general upkeep, however, later incoming travelers were required to pay their hotel fees. These deficiencies made contact tracing and surveillance more challenging, especially with increasing case volume. Across all study countries, as the pandemic gained momentum and funds became depleted, the institutional quarantine and isolation strategies were changed to home based quarantine and isolation. Compliance with self-isolation and self-quarantine became a challenge in the drive to prevent and control the epidemic resulting in increased community transmission of the virus [ 35 ].

Weak surveillance infrastructure - The health infrastructure in all countries was weak and not adequately situated to manage a global pandemic. There was inadequate health manpower and funds designated for COVID-19 surveillance (Table  4 ). Surveillance tools and logistics were also not readily available in the early stages of the pandemic. The decentralized and community surveillance structures had varying degrees of performance and required additional support especially in data analysis and use, postmortem surveillance and tracking of excess deaths across the study countries.

“When community transmission took off and we had overwhelming cases, the contacts were also too many yet the resources for the district teams to move to where cases had been identified, contact listing and monitoring were limited and it became impracticable to follow up contacts so that arm of surveillance contact tracing to detect cases has over time become very limited in its implementation” ( Surveillance Officer, Uganda ).

Community stigma and misinformation - There was poor public perception of the cause and prevention of COVID-19, and there were many misinformation and conspiracy theories about the pandemic on social media across all the four countries. This affected the care seeking behaviors of the populations including testing among contacts and symptomatic individuals and ultimately the disease surveillance.

“Another challenge was the perception of the public… there was a lot of misinformation… We had several negative experiences with contacts and their families. Logistics was also an issue as we didn’t have enough vehicles to do contact tracing. Some of us were working with our personal cars and we wouldn’t get reimbursed when we hired vehicles. It was quite daunting as we didn’t have much technical manpower. In one day, I trained 3 sets of contact tracers” (Surveillance Pillar Member, State EOC, SS Nigeria) “People are not ready to cooperate with us most of the time because they are afraid and ashamed, it affects surveillance because the confirmed case will have exceeded the incubation period before we can get to them” (Laboratory Team Member, State EOC, SW, Nigeria) “The problem of surveillance is the non-disclosure of suspected cases, the population considers this as a denunciation / betrayal vis-à-vis their parents or their neighbors. This shows how the disease is perceived by populations, it is a shameful disease. (Member of Health District Team Management-Senegal) “ It was not easy to manage COVID-19 because in all the structures, people did not want to believe that the disease existed. For most Congolese, COVID-19 is an invention of the whites to eliminate the Africans ” (Member, National Committee for Epidemiological Surveillance, DRC).

Summary of findings

Disease surveillance systems are developed for the monitoring of the health status of populations and most importantly for early detection of infectious diseases outbreaks and prompt intervention. Surveillance is a top priority in management and control of any pandemic. Countries’ responses to emergent health crises depend mainly on the strength of the surveillance systems they establish [ 36 ]. This study aimed to document the COVID-19 surveillance strategies adopted by DRC, Nigeria, Senegal and Uganda in response to the COVID-19 pandemic as well as to describe the strengths, weaknesses, and lessons learnt about the existing surveillance approaches adopted during the epidemic. Furthermore, the aim of the study was to gather evidence on functionality of the adopted surveillance so as to inform the enhancement of surveillance systems to facilitate preparedness for future epidemics in Africa.

Surveillance for COVID-19 cases was risk-based across all four countries and involved a combination and networking of several surveillance methods. It was found that all countries had previous experiences with managing surveillance systems in an epidemic situation such as Ebola disease and were therefore, able to respond promptly to the pandemic but insufficiently due to resource constraints. For example, the national Emergency Operation Centre (EOC) in Nigeria had been in existence and had ample experiences in polio as well as in Ebola outbreak surveillance and response. The key strengths across the studied countries included leveraging on these previous outbreak experiences and pre-existing functional surveillance systems, strengthened surveillance capacity at sub-national levels by training rapid response teams at subnational levels; establishment of databases with capacity to report on key indicators on COVID-19 response, including electronic systems linked to DHIS-2 which contributed to regular review and update of surveillance policies and strategies. Developed countries on the other hand have standardized surveillance response system with skilled technical staff.

All four countries adopted realtime and active contact tracing as one of the essential surveillance approaches so as to control the disease through empowering decision makers with information on the health-related behaviors of their communities and the spread of the COVID-19 disease in the community. This enables the governments of the study countries to intervene quickly to stop the spread of disease. The priority groups for contact tracing included high-risk persons such as contacts of confirmed cases, and travelers from countries with reported COVID-19 cases, but prioritization was revised to include only symptomatic contacts and travelers, as the pandemic progressed. Furthermore, contact tracing was decentralized at a later time to target individuals at higher risk of severe disease.

The key challenges and gaps included; inadequate human resources for surveillance activities especially at lower levels; insufficient space for institutional quarantine and isolation; low case detection rates; limited capacity for routine genomic sequencing of variants; weak decentralized surveillance capacity; insufficient infrastructural capacity for quarantine and isolation; weak health care infrastructure including inadequate funds and tools for surveillance activities; misinformation and poor public perception about COVID-19, especially on social media. For example, inadequate human resources limited the optimal performance of surveillance systems. This was corroborated by the overwhelming load of contact tracing workload for healthcare workers reported in other studies where Uganda had 186/100,000 population and Nigeria had 111 per each state with populations in millions [ 25 ]. There was also humanitarian assistance from donors such as WHO, UN baskets, non-govermental organizations and the Nigerian indigenous Coalition against COVID-19. The world bank provided funds for contact tracing and Africa Centres for Disease Control and Prevention funded active case search.

Inadequate human resources and other challenges moderated the gains that would have accrued from adapting already existing surveillance systems and experience in managing outbreaks. The UK support initiative and Clinton health access initiative supported state and local capacity building and ongoing vaccine development.

As the pandemic progressed, the resources available could not cope with upsurge in activities required to maintain standard operating procedures leading to modifications in surveillance strategies. The criteria for testing and contact tracing were streamlined to reduce the workload. Isolation and quarantine facilities were expanded to private facilities with the implication of poorer follow-up and monitoring. Furthermore, all countries reported gaps in data management and surveillance response at subnational levels. The importance of task shifting to community health workers, adopting technology based solutions, strong national leadership including enhancing multisectoral partnership to respond to the pandemic was adopted. The countries prioritized national-level coordination of the various surveillance approaches across sectors and stakeholders. Each country established or leveraged robust partnerships with non-governmental organizations, academics, and other global institutions. These countries improved data management and surveillance capacity rapidly by training health workers and increasing resources for laboratories, but the disease burden continued to be under-detected.

Results in context of the literature

A key objective of the World Health Organisation’s COVID-19 surveillance is to guide the implementation and adjustments of COVID-19 control measures including isolation of cases, contact tracing and quarantine of contacts [ 37 ]. The experience of African countries in handling previous infectious disease outbreaks and the existing surveillance infrastructure were helpful and in part made Africa fare better in COVID-19 pandemic compared to the high-income countries [ 38 ]. The exising surveillance infrastructure was revitalized and repurposed for COVID-19 surveillance. The surveillance methods documented in this study was corroborated by a systematic review of COVID-19 surveillance systems in 13 other African countries which documented the similar surveillance methods reported in this study [ 21 ]. Some variations however, exist in the level of implementation of the surveillance strategies between the countries which determines to a large extent, the representativeness of the systems. South Africa with more comprehensive surveillance system reported more representative COVID-19 burden data compared to countries such as Tanzania and our four study countries where COVID-19 surveillance strategies were poorly developed [ 21 ]. The interpretation of the morbidity and mortality burden from COVID-19 is subject to the quality of the surveillance system adopted. The surveillance systems in the four African countries under study have been generally non-representative of the entire underlying population. The seroprevalence surveys conducted in these countries reported a much higher COVID-19 prevalence than would be expected by the number of cases reported.

Therefore, there is a need for these countries to utilize multiple surveillance approaches to understand the full picture of the disease burden. The risk based testing strategy adopted by the countries underestimated the burden of COVID-19 due to underreporting. Extending COVID-19 testing to all contacts of a confirmed case would give a better sense of the disease burden but this attracts high cost which the countries may not have the capacity to afford and sustain. Hence, additional sources of data may be needed for example from mortality surveillance, and community surveys which were not fully integrated. A study in Zambia found significant excess mortality due to COVID-19, with the majority of deaths occurring in the community that were undiagnosed, while many deaths at the facility were also un-tested prior to death [ 39 ]. Mortality surveillance and all-cause mortality tracking has generally not been widely practiced in many African countries. Uganda attempted to establish a mortality surveillance system and has been conducting post-mortem surveillance for hospital and community COVID-19 deaths, but this has remained weak due to challenges in mortality reporting in the health systems. In Nigeria, the serological surveys conducted confirmed much higher COVID-19 prevalence than reported through the regular surveillance system, thereby emphasizing the importance of using multiple surveillance methods.

Implications for epidemic preparedness and response

During the epidemic these countries made efforts to upgrade and upscale the health systems infrastructure so as to improve resilience and to enhance rapid response to infectious diseases emergencies.

Generally, all the four countries started planning early and had a fairly slow buildup of COVID-19 cases. The study revealed the existence of a emerging framework for surveillance structure and system in the four countries. At the onset of the pandemic, all four countries under study had in place limited existing surge capacities mainly in the areas of laboratory testing and trained epidemiologists with limited dedicated funds for outbreak response management such as contact tracing. Nigeria, Senegal and Uganda all reported having dedicated budgets for outbreak response which were available at the beginning of the outbreak for provision of personal protective equipment and limited contract tracing [ 35 ].

The existing surveillance systems in all the countries were built to respond to localised epidemics whereby the central level response team would support the decentralized rapid response team (RRT) at the outset of an outbreak. However, the subnational structures have never been activated into full preparedness response mode. At the same time the countries were never prepared for simultaneous country-wide outbreak response in multiple geographic locations. In the event of a widespread pandemic such as COVID-19, all countries experienced challenges in subnational responses including shortages in adequately trained surveillance officers, data analyst and contact tracers. Building the capacity of subnational epidemic response capacity requires substantial resources allocation including funding, training staff, and equipping the decentralized centers. Due to resource constraint, a strategy adopted by the countries was to prioritize the districts or regions at highest risk i.e., geographies with higher number of cases. For example, in the DRC, surveillance efforts were strongest in Kinshasa which was the epicentre of the epidemic and where mass testing centres and several diagnostics laboratories were established.

There was deliberate modification in the daily schedule of human resources in communities and at health facilities to reduce their work load and lessen the risk of contracting COVID-19 [ 12 ]. Furthermore, countries did not have the appropriate number of responders. For example, there was a lack of adequate contact tracers to match the pandemic demand across all countries. In addition, the study countries still have challenges with ensuring the availability of adequate and appropriately skilled human resource, a situation that preceded the pandemic and that will require strategic resourcing during and after the COVID-19 pandemic. The countries could rapidly train, repurpose, and deploy community-based voluntary health workers (VHW) and facility-based health workers, but these structures require additional strengthening for epidemic preparedness and rapid response.

Overall, analysis and use of surveillance data for action existed at the central/national level but was limited at the subnational levels in all the studied countries. Ensuring timely data availability and use of data is critical to public health decision making. During the pandemic crisis we observed the importance of having the right data which was routinely used for EOC guidance. Therefore, countries had strategies to report data daily, weekly and monthly. The study countries in various degrees adopted electronic systems from paper-based to improve efficiency of data transmission and data use for decision making. Availability of surveillance data contributed to regular review and update of the existing surveillance policies, strategies and standard operating procedures. However, there were notable gaps in data accuracy and consistency at non-sentinel sites than at sentinel sites. Furthermore, the data were not disaggregated by socio-demographic characteristics such as sex, location/place of residence to show burden at the individual level characteristics. The establishment of databases linking surveillance with testing that were accessible to key stakeholders improved communication and efficiency. Data systems development and use require improvement at the subnational levels for more efficient response.

Technological innovations were deployed to enhance surveillance activities including contact tracing, monitoring persons in quarantine, reporting, data analysis, laboratory results return, with improved efficiency. For example, Senegal adopted and used digital communication innovations such as the “Alerte Santé Sénégal” app and “Sunucity” which is an incident reporting app for suspected COVID-19 cases from community that allows feedback from the authorities [ 12 ]. These need to be evaluated and replicated.

Strengthening partnerships is key for epidemic preparedness and response. The studied countries were able to source initial supplies with support from non-governmemtal organizations, philanthropists and international partners. The private sector provided funding for testing kits and built facilities for quarantine and isolation services as a surveillance measure. However, the countries need to optimize the public private partnerships in several areas including provision of health services and manufacture of health products. South-to-South COVID-19 response collaboration and technical support can be fostered as a result of the countries’ differential experience. For example, Nigeria and Uganda with expertise in capacity building for epidemic preparedness among responders can be a resource in this area in the region.

Furthermore, there is a need for the improvement of the alert management systems for identification of COVID-19 cases or any other epidemic disease from the community. Senegal, Nigeria and Uganda, reported using call centers with toll free lines to support case identi.fication and contact tracing. However, these call centers were eventually overwhelmed and response became suboptimal as the pandemic progressed with widespread community transmission. Routine alerts could be supplemented with other active surveillance approaches such as systematic health facility surveillance, mortality surveillance and periodic surveys for better estimation of the burden of disease and disease outcomes.

Study limitations

A substantial part of this study relied on document review. At times the codified evidence in guidelines, policy documents and scientific publication may differ from the real world experience or may lag behind on what could be happening on the ground. Thus, the extent to which the documents reviewed reflected the true practice is uncertain. However, the study mitigated this potential bias by triangulation the literature review information with the qualitative interviews.

This study did not assess the relative performance or effectiveness of surveillance methods. Surveillance methods adopted in the countries studied were complementary. In the face of resource challenges, there is a need to adopt the most comprehensive and cost-effective methods. For example, the European Centre for Disease Preventiion and Control recommended for member countries no longer testing mild suspected cases of COVID-19 should integrate COVID-19 surveillance with sentinel surveillance of influenza-like illness or acute respiratory infection [ 40 ]. The swabs obtained at the sentinel sites would then be tested for SARS-CoV-2 in addition to influenza virus. This provides some cost saving by using existing resource framework.

The article showed that private sector contributed immensely to COVID-19 response such as surveillance and testing, treatment, risk communication, health promotion and maintenance of access to essential health services.

Following the COVID-19 outbreak on the African continent in February- March 2020, the DRC, Nigeria, Senegal and Uganda demonstrated a prompt public health response to the epidemic ass well as instituted national policies aligned to WHO guidance and modified these strategies along the phases of the local epidemic. The countries adopted similar approaches to surveillance, although at different levels and with slight modifications. All four stiudy countries seemingly performed well at the initial stages of preventing transmission through quarantine and isolation. However, as the number of COVID-19 cases began to increase the quarantine and isolation approach began to fault.Coordination of the COVID-19 response in all four study countries built on existing surveillance systems with establishment of central task teams. All countries noted capacity gaps for response at subnational level and adopted electronic systems for data management at varying levels; and they utilized web-based platforms for public data access and visualization. Across four countries, one common challenge was lack of human resource capacity for conducting contact tracing, data analysis, as well as public health expertise.

Recommended approaches such as (1) adopting more innovative technological solutions to improve efficiencies of their surveillance strategies, (2) having a central database across the response pillars to make surveillance more efficient and improve data use at the subnational level, can help stem the further spread of COVID-19, while enhancing readiness for future disease outbreaks. Other approaches include, (3) improvement of human resource surge capacity at subnational level, (4) decentralization of isolation centers and (5) enhancement of home/self-isolation with support from community structures. The private sector should be involved to support response activities, while ensuring proper regulation and quality assurance. Efforts to stem further spread of COVID-19 are critical including roll-out of COVID-19 vaccines, and implementation of targeted non-pharmaceutical interventions.

Data Availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

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This work was supported in whole or in part, by the Bill & Melinda Gates Foundation [Opportunity ID: INV-019313]. The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the views, opinions, or policies of the Bill and Melinda Gates Foundation.

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Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria

Olufunmilayo Ibitola Fawole, Segun Bello, Ayo Stephen Adebowale, Eniola Adetola Bamgboye, Mobolaji Modinat Salawu, Rotimi Felix Afolabi & Magbagbeola David Dairo

Makerere University School of Public Health, Kampala, Uganda

Alice Namale, Suzanne Kiwanuka, Fred Monje, Noel Namuhani, Steven Kabwama, Susan Kizito, Rawlance Ndejjo & Rhoda Wanyenze

Department of Preventive Medicine and Public Health, Université Cheikh Anta Diop de Dakar, Dakar, Senegal

Ibrahima Seck, Issakha Diallo, Mamadou Makhtar, Mbacke Leye, Youssou Ndiaye, Manel Fall & Oumar Bassoum

Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo

Mala Ali Mapatano, Marc Bosonkie & Landry Egbende

Gates Ventures LLC, Exemplars in Global Health, Seattle, WA, USA

Siobhan Lazenby, William Wang, Anne Liu & Rebecca Bartlein

Bill and Melinda Gates Foundation, Seattle, USA

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OIF, IS, MAM and RW were involved in study conceptualization and drafting of the protocol. All authors were involved in the review of study protocol, planning, data collection, data analysis and interpretation and drafting of the study report. OIF and SB developed the first draft of the manuscript. All authors reviewed and approved the final version of the manuscript.

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The study was conducted in accordance with the Declaration of Helsinki. The desk review obtained permission of the gatekeepers’ to allow access to the facilities. Written and verbal informed consent was obtained from the participants. Ethical clearance for each country was gotten from relevant national and Institutional Review Boards DRC: Kinshasa School of Public Health Ethics Committee No d’Approbation: ESP/CE/198/2020; Nigeria: National Health Research Ethics Committee NHREC/01/01/2007 Senegal: National Committee of Ethics and Research 000279/MSAS/DPRS/DR 03/03/2021; Uganda: Makerere University School of Public Health Higher Degrees Research and Ethics Committee UNCST HS 1121ES/HDREC 903.

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Fawole, O.I., Bello, S., Adebowale, A.S. et al. COVID-19 surveillance in Democratic Republic of Congo, Nigeria, Senegal and Uganda: strengths, weaknesses and key Lessons. BMC Public Health 23 , 835 (2023). https://doi.org/10.1186/s12889-023-15708-6

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COVID-19 surveillance in Democratic Republic of Congo, Nigeria, Senegal and Uganda: strengths, weaknesses and key Lessons

Affiliations.

• 1 Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria. [email protected].
• 2 Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria.
• 3 Makerere University School of Public Health, Kampala, Uganda.
• 4 Department of Preventive Medicine and Public Health, Université Cheikh Anta Diop de Dakar, Dakar, Senegal.
• 5 Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo.
• 6 Gates Ventures LLC, Exemplars in Global Health, Seattle, WA, USA.
• 7 Bill and Melinda Gates Foundation, Seattle, USA.
• PMID: 37158897
• PMCID: PMC10165588
• DOI: 10.1186/s12889-023-15708-6

Introduction: As part of efforts to rapidly identify and care for individuals with COVID-19, trace and quarantine contacts, and monitor disease trends over time, most African countries implemented interventions to strengthen their existing disease surveillance systems. This research describes the strengths, weaknesses and lessons learnt from the COVID-19 surveillance strategies implemented in four African countries to inform the enhancement of surveillance systems for future epidemics on the continent.

Methods: The four countries namely the Democratic Republic of Congo (DRC), Nigeria, Senegal, and Uganda, were selected based on their variability in COVID-19 response and representation of Francophone and Anglophone countries. A mixed-methods observational study was conducted including desk review and key informant interviews, to document best practices, gaps, and innovations in surveillance at the national, sub-national, health facilities, and community levels, and these learnings were synthesized across the countries.

Results: Surveillance approaches across countries included - case investigation, contact tracing, community-based, laboratory-based sentinel, serological, telephone hotlines, and genomic sequencing surveillance. As the COVID-19 pandemic progressed, the health systems moved from aggressive testing and contact tracing to detect virus and triage individual contacts into quarantine and confirmed cases, isolation and clinical care. Surveillance, including case definitions, changed from contact tracing of all contacts of confirmed cases to only symptomatic contacts and travelers. All countries reported inadequate staffing, staff capacity gaps and lack of full integration of data sources. All four countries under study improved data management and surveillance capacity by training health workers and increasing resources for laboratories, but the disease burden was under-detected. Decentralizing surveillance to enable swifter implementation of targeted public health measures at the subnational level was a challenge. There were also gaps in genomic and postmortem surveillance including community level sero-prevalence studies, as well as digital technologies to provide more timely and accurate surveillance data.

Conclusion: All the four countries demonstrated a prompt public health surveillance response and adopted similar approaches to surveillance with some adaptations as the pandemic progresses. There is need for investments to enhance surveillance approaches and systems including decentralizing surveillance to the subnational and community levels, strengthening capabilities for genomic surveillance and use of digital technologies, among others. Investing in health worker capacity, ensuring data quality and availability and improving ability to transmit surveillance data between and across multiple levels of the health care system is also critical. Countries need to take immediate action in strengthening their surveillance systems to better prepare for the next major disease outbreak and pandemic.

Keywords: COVID-19 response; COVID-19 surveillance; Health systems; Key learnings; Lesson learnt; Strengths and weaknesses.

© 2023. The Author(s).

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Authors have nothing to disclose.

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Lessons from co-production of evidence and policy in nigeria’s covid-19 response, attachments.

Ibrahim Abubakar, Sarah L Dalglish, Chikwe A Ihekweazu, Omotayo Bolu, Sani H Aliyu

Correspondence to Professor Ibrahim Abubakar; [email protected]

In February 2020, Nigeria faced a potentially catastrophic COVID-19 outbreak due to multiple introductions, high population density in urban slums, prevalence of other infectious diseases and poor health infrastructure. As in other countries, Nigerian policymakers had to make rapid and consequential decisions with limited understanding of transmission dynamics and the efficacy of available control measures. We present an account of the Nigerian COVID-19 response based on co-production of evidence between political decision-makers, health policymakers and academics from Nigerian and foreign institutions, an approach that allowed a multidisciplinary group to collaborate on issues arising in real time. Key aspects of the process were the central role of policymakers in determining priority areas and the coordination of multiple, sometime conflicting inputs from stakeholders to write briefing papers and inform effective national decision making. However, the co-production approach met with some challenges, including limited transparency, bureaucratic obstacles and an overly epidemiological focus on numbers of cases and deaths, arguably to the detriment of addressing social and economic effects of response measures. Larger systemic obstacles included a complex multitiered health system, fragmented decision-making structures and limited funding for implementation. Going forward, Nigeria should strengthen the integration of the national response within existing health decision bodies and implement strategies to mitigate the social and economic impact, particularly on the poorest Nigerians. The co-production of evidence examining the broader public health impact, with synthesis by multidisciplinary teams, is essential to meeting the social and public health challenges posed by the COVID-19 pandemic in Nigeria and other countries.

Summary box

In Nigeria, policymakers used a co-production model linking political decision-makers, health policymakers and academics from diverse disciplines to maximise the speed, relevancy and impact of scientific data and evidence to respond to COVID-19.

This model allowed a multidisciplinary group to collaborate on issues arising in real time, with demonstrated impact on national decision making and apparently limiting the virus’ spread.

Challenges of the co-production model included limited transparency, bureaucratic obstacles and an overly epidemiological focus on direct impacts of the disease compared with the social and economic effects of response measures.

Integration of epidemiological, social science and economic analyses by multidisciplinary teams, in concert with policymakers, provides a strong path to meeting the twinned social and public health challenges created by COVID-19.

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The dynamics of COVID-19 outbreak in Nigeria: A sub-national analysis

Kayode p. ayodele.

a Department of Electronic, and Electrical Engineering Obafemi Awolowo University, Nigeria

Hafeez Jimoh

b Intelligent Robotic Systems Laboratory Innopolis University Innopolis City, Russian Federation

Adeniyi F. Fagbamigbe

c Department of Epidemiology and Medical Statistics University of Ibadan, Nigeria

Oluwatoyin H. Onakpoya

d Department of Medicine Obafemi Awolowo University, Nigeria

The African health crisis feared at the beginning of the COVID-19 pandemic has not materialized, and there is interest globally in understanding possible peculiarities in COVID-19 outbreak dynamics in the tropics and sub-tropics that have led to a much milder African outbreak than initial projections. Towards this, Susceptible-Infected-Recovered-Dead compartmental models were fitted to COVID-19 data from all Nigerian states in this study, from which four parameters were estimated per state. A density-based clustering method was used to identify states with similar outbreak dynamics, and the stage of the outbreak determined per state. Subsequently, outbreak dynamics were correlated with absolute humidity, temperature, population density and distance to the international passenger travel gateways in the country. The models revealed that while the outbreak is still increasing nationally, outbreaks in at least 12 states have peaked. A total of at least 519,672 confirmed cases were predicted by January 2021, with a worst case scenario of at least 14,785,457. Weak positive correlations were found between COVID-19 spread and absolute humidity (Pearson’s Coefficient = 0.136, p < 0.05) and temperature (Pearson’s Coefficient = 0.021, p < 0.05). While many studies have established links between temperature and humidity and COVID-19 spread, the correlation has most usually been negative where it exists. The findings in this study of possible positive correlation is in line with a number of previous studies showing such unexpected correlations in the tropics or subtropics. This highlights even more the importance of additional studies on COVID-19 dynamics in Africa.

Introduction

The coronavirus disease (COVID-19) first broke out in the city of Wuhan, Hubei Province in China in late December 2019 [20] . With rapid spread across countries especially across Europe, COVID-19 was declared a pandemic by the WHO on March 12 2020 [20] . It has since spread to nearly all countries and continents. The virus has continued to wreak havoc in different countries at an alarming pace [3] . As of August 12 2020, there are 20,836,339 cases of the virus with nearly 750,000 causalities [32] . The first case of the virus emerged in Nigeria on February 28, 2020 and has increased rapidly within 6 months to 47,743 cases with 979 deaths as of August 12, 2020 [32] .

Compared with the number of cases and causalities in the Central America and Europe, Africa currently has a lower burden of COVID-19. These may be ascribed to differences in environmental conditions and the fact that the breakout started later in Africa than most places thereby providing a window of opportunity for preparedness and mitigation efforts such as lock-down. However, Africa has the largest proportion of less developed countries than other continents. The continent nonetheless suffer dearth of medical supplies, very low baseline of and access to hospitalisation capacity, particularly intensive and sub-intensive care. Other parameters such as larger household sizes, higher intergenerational mixing within households, poorer environmental conditions including overcrowded urban settlements, inadequate water and sanitation, pre-existing disease burden with higher prevalence of both undiagnosed, poorly-managed and unmanaged noncommunicable diseases. This health outcomes may be risk factors for COVID-19 severity. Bearing in mind that Africa had the highest burden of infectious diseases, such as HIV, TB, malaria, ebola etc, which might have a negative impact on the longtime severity of COVID-19. There is need for multi-sectoral efforts to stimulate understanding of the spread and severity of the virus in Africa. One of such efforts is modelling of the different characteristics of the virus.

Beside sharing the peculiarities of other Africa countries, the fragile healthcare systems in Nigeria is beginning to be overwhelmed. There are concerns that the current situation may worsen. Nigeria, as the most populous African country, occupies a delicate and strategic position in the continent. An inefficient management of the pandemic may affect other African countries negatively. Very central to the efforts targeted at developing, planning and implementing containment and mitigation measures in Nigeria is understanding and modelling the spread of the virus. Nigeria is however diverse in terms of access to health care, household structures, geographical features, weather, etc. We hypothesized that these differences may affect the spread, recovery from and severity of COVID-19 across the different States in Nigeria. The current study is therefore aimed at modelling and understanding the within-country dynamics of COVID-19 outbreak in Nigeria in terms of number of cases, number of recoveries and number of deaths from COVID-19.

Modelling the spread of the virus worldwide has remained a big task because most parameters about the virus is not known. Since the virus was declared a pandemic, modellers consisting of engineers, mathematicians, Statisticians and data scientists have been presented with daunted task of understanding and modelling the nature, the spread as well as other characteristics of the virus [11] .

Several approaches have been engaged in modelling COVID-19 since its outbreak [6] , [22] , [33] , [35] , [36] . Modelling of an infectious disease, irrespective of its purpose to understand, track and predict its behaviour and behaviour,is very paramount to strategies to control and mitigate the spread of the disease. According to [21] , the earliest infectious modelling efforts was in 1662 by John Graunt [21] , mathematical modelling of the spread of diseases by Bernoulli in 1766 [23] , and the popular foundation of compartmental modelling of epidemics between 1927 and 1933 [14] , [15] , [16] . More recently, different modelling strategies have been developed. The strategies are dynamic and are diverse [23] . Siettos et al. categorised the recent modelling strategies into: (i) statistical-based methods for epidemic surveillance, (ii) mathematical and mechanistic state-space models, and (iii) empirical and machine learning-based methods [23] . The most popular infectious disease models (including those used by the WHO) employed the SIR (Susceptible - Infectious - Recovered), SEIR (Susceptible - Exposed - Infectious - Recovered) and SIRD (Susceptible-Infected-Recovered-Dead) models. They followed establishment of the basic reproduction number, assessment of herd immunity as well as significant clusters. Fong et al. and Wang et al. had used this approach to predict infection rate and spread [11] , [29] . The current study utilized the SIRD model.

0.1. Data sources

Data on the COVID-19 outbreak in Nigeria were obtained from the COVID-19 microsite of the Nigeria Center for Diseases Control (NCDC) [8] . State-wise data were extracted from individual daily reports for the period between 1st March, 2020 and August 10, 2020. COVID-19 country data for Nigeria were also obtained from the Johns Hopkins University Coronavirus Resource Center repository [28] to validate the extracted NCDC data.

Historical temperature and relative humidity data were obtained from the National Centers for Environmental Information (NCEI) library through the Visual Crossing Weather Data Services web application [5] . Monthly average data for 36 states and the Federal Capital Territory (FCT) were extracted. Absolute humidity was estimated from relative humidity using the Clausius Clapeyron conversion relation [12] , [13] :

State population and geographical information data were were obtained from the Nigeria National Bureau of Statistics (NBS) [25] . Population values for the period 2011 - 2015 were obtained and the value for 2020 estimated by linear extrapolation.

0.2. Compartmental model and notation

The Susceptible-Infected-Recovered-Dead (SIRD) model is a standard infectious disease model for analysing infectious disease outbreak dynamics by tracking the variations with time of the four eponymous variables [10] . In this model, outbreak dynamics are modelled with the following four ordinary differential equations:

where T is time elapsed since the outbreak started, α is the mortality rate, β is the effective contact rate, and γ is the recovery rate. S, I, R, F, N are the susceptible, infected, recovered, dead, and total populations respectively. Also,

In order to more easily compare outbreak dynamics across areas with different populations, the following non-dimensional variation of the SIRD model was adopted in this study:

in which t = T / τ where τ is a time scaling constant of convenient value. Also, s = S N , i = I N , r = R N , D = D N , while κ = α τ , ρ = β τ , and σ = γ τ are population-normalized versions of the mortality, effective contact, and recovery rates.

The reproduction rate, R 0 was estimated as follows:

Case fatality rate was computed as the ratio of the number of deaths and the number of confirmed cases. An distinction is made between the number ”infected” cases (individuals currently infected) and the ”confirmed” cases (cumulative sum of all individuals ever confirmed to be infected, whether or not they have recovered, died, or remain infected).

0.3. Data analysis

Visual inspection of daily case reports revealed that the COVID-19 data were generally noisy. One incidence deserves special mention. On August 3, 2020, the number of discharged patients for Lagos state increased by 10946. The mean daily increment prior to that was 13 patients. The following annotation accompanied the 3rd August discharge number: ”Number includes recoveries from treatment centre and community recoveries managed at home” [7] . Evidently, Lagos state must have taken some time to arrive at a reasonably accurate estimation of the number of cases treated outside official healthcare centers in the state, triggering the adjustment by the NCDC on August 3. This is justifiable, but nevertheless creates certain challenges for COVID-19 outbreak modelling for Lagos and Nigeria.

A one-day spike of that magnitude in discharge numbers is inconsistent with normal infectious disease outbreak dynamics. In this study, two version of the Lagos data were used. The first version employed the raw data as reported by the NCDC, including the spike on 3rd August. In addition, a new dataset was introduced in which the Lagos data was adjusted. Using a ramp function, the 10946-case spike was spread across multiple days. Starting from 1st April and ending on August 3, the 10,946 discharged cases were added to previously recorded discharges for the days, so that the number of cases added for each day increased by a fixed value. Consequently, this study used data for 39 ”regions”: the FCT, 36 states unmodified, a 38 t h fictitious state termed ”Lagos-Adj” for the modified Lagos data, and the cumulative nationwide data for comparison where appropriate.

Daily information for all states were plotted showing confirmed cases, discharged and deaths for a total of 38 states and the national cumulative. Subsequently, each of the 39 datasets were fitted to SIRD models represented by (7) , (8) , (9) , (10) . The value of τ was set to 180. Parameter estimation for κ , ρ , σ was carried out on dataset data using the hyperparameter optimization method implemented by the Optuna Python programming language package [1] with a root mean squared log error (RMSLE) cost function, which is robust to the effects of outliers [24] .

Compartmental modelling was carried out in the Covsirphy infectious disease modelling library [26] . The SIRD model parameters were assumed to be time-varying throughout the outbreak. However, in order to make the models tractable, a small number of inflection point were assumed, at which model parameters changed. Detection of these inflection points was achieved using phase plane analysis in the SR plane [4] as follows. From Eqs. 2 and 4 ,

By plotting this function for each dataset, the inflection points were determined, and the intervening periods between points defined as phases during which the parameters κ , ρ , σ and R 0 were assumed constant. Furthermore, a growth factor time series was computed for each dataset. Where Δ C n was increase in the number of confirmed COVID-19 cases between day n − 1 and day n , the growth factor F g was defined as:

The current outbreak stage per state was categorized as expansion, contraction or indeterminate on the basis of growth factor values over rolling 7-day epochs, and using the reproduction number, R 0 . For investigating similarities between the outbreaks in different states, 4-dimensional vectors created from the average values of κ , ρ , σ and R 0 for each state were clustered by means of hierarchical density based clustering [19] . Furthermore, possible relationships between the outbreak and various factors were investigated using linear correlation analysis, including temperature, absolute humidity, and distance from Nigeria’s commercial and administrative capitals.

Using the values of the model parameters as at August 10, simulations were run with the SIRD models to project the size of the different populations till the end of December 2020.

Between March 1, and August 10, a total of 46,866 confirmed cases COVID-19 of were reported in Nigeria, from a total of 321,950 tests conducted. There were confirmed COVID-19 cases in every state and the FCT. As at August 10, 2020, there were 33,346 discharged cases, and 950 confirmed fatalities, leading to a case fatality rate of 2.0% [9] . Figs. 1 and ​ and2 present 2 present the cumulative numbers of confirmed cases, recovered (discharged) cases, and deaths over time for 38 states and nationwide.

Daily variations in the Infected, Discharge and Death populations for 20 datasets.

Daily variations in the Infected, Discharge and Death populations for remaining 19 datasets.

The values of parameters κ , ρ , σ , and R 0 for the duration of outbreak evolution in each state are presented in Fig. 3 . To improve the figure, each parameter was scaled by an appropriate factor (indicated at the bottom). There is no plot for Kogi state because the low number of cases prevented the model from converging. Case fatality rates as of August 10, are presented in Fig. 4 . There is only one entry for Lagos because the August 3, 2020 adjustment affected neither the total number of confirmed cases nor the deaths from COVID-19.

Variations in the parameters κ , ρ , σ and R 0 for different phases across the different states. Cross River and Kogi States are excluded.

Case fatality rates for 36 states, FCT, and national average.

Figs 5 and ​ and6 present 6 present the S-R curves generated for trend analysis of the Lagos and Lagos-Adj datasets respectively. The effect of the spike in discharged cases on August 3, on the trend analysis is evident, as the Lagos outbreak was segmented into 4 phases, rather than the 9 phases identified in the adjusted Lagos data. Similarly, the effect of the adjustment on the reproduction number of Lagos can be seen in Fig. 3 differing by an order of magnitude (1.24 versus 14.77).

Outbreak dynamics in certain states were inordinately affected by the low number of COVID-19 cases. Nowhere is this more evident than in the case fatality rate for Kogi state (40% in Fig. 4 ), a figure that was obviously impacted by the unreliability of most statistics at small sample sizes [31] . In fact, of the states with the highest CFR (Anambra, Cross River, Kebbi, Sokoto, Taraba, Yobe, Zamfara) only Anambra has more than 100 confirmed cases as of August 10, 2020. Consequently, all states with less than 100 cases were excluded from further analysis. The relationship between CFR and number of confirmed cases was investigated by means of a correlation analysis, and revealed a weak but statistically significant relationship between number of cases and CFR (Pearson coefficient of -0.22; T-statistic = 84.44; p-value = 4.0 x 10 − 42 ).

Table 1 presents the result of the analysis of current outbreak stage per state. Growth factor analysis categorized 13, 5, 17 states as contraction, expansion, and indeterminate stages respectively. Using the more traditional reproduction number approach in which outbreak contraction is determined by R 0 < 1 , 22 state outbreaks were classified as contracting, while 13 were still expanding. A cluster analysis using the parameters of the SIRD model as feature vectors resulted in five clusters as shown in Fig. 7 .

Determination of the stages of outbreaks per state using growth factor and using R 0 .

Clustering of COVID-19 outbreak dynamics in different states using density based clustering.

The population densities, average temperature and absolute humidity for the periods between March and August 2020 for each of the 36 states and the FCT are presented in Table 1 . Also in Table 1 are the average beeline distances between the respective state capitals and Lagos and Abuja, where the two primary international passenger traffic gateways of the country are located. The Pearson’s coefficient for the correlation analysis between ρ and four variables are presented in Table [2]. From Eqs. 7 and 8 , ρ is the parameter in the SIRD model most associated with the rate of outbreak expansion. No relationship was found between ρ and the population densities of states (p > 0.05). The table however suggests a weak negative correlation between both temperature and absolute humidity (p < 0.05).

Table 4 presents the results of simulations of the SIRD models for states till the end of 2020 assuming that model parameter values on August 10, 2020 stay constant. It should be noted that Kogi and Cross River state simulations failed to converge due to insufficient data, so the Total row is sans those two states.

Average absolute humidity and temperature of different states and distances to Lagos and the FCT.

Pearson’s coefficients and p-values for correlations between ρ and three parameters.

Projected outbreak population sizes by December 31, 2020 assuming a worst case scenario.

*excluding Cross River and Kogi States

Projected outbreak population sizes by December 31, 2020 using SIRD model parameters as of August 10, 2020.

Generally speaking, variations can be seen in all important COVID-19 outbreak parameters and metrics across Nigeria. Whether those variations are sufficient for accurate inference however depends on important extenuating factors including the current extent of the outbreak per location, and the quality of data collation and management. For the first factor, the outbreaks in certain state are too small to accord statistical significance to certain parameters, most notably in the case of Kogi state, but also in most states with less than 100 confirmed cases. The question of data quality comes up primarily in the case of Lagos State, since the one-time adjustment of August 3, 2020 significantly affected multiple outbreak parameters not just in Lagos, but across the whole country. The problem can however be glimpsed in sudden spikes and drops in different categories of numerous state data such as Nasarawa, Ondo, Taraba, Yobe and Zamfara states ( Figs. 1 and ​ and2). 2 ). More important than the magnitudes of these occasional spikes and drops is what their existence suggests about the accuracy with which certain records are generated and propagated to the NCDC. The immediate consequence of these extenuating factors is that trends and effects that might otherwise have emerge from analysis may be occluded.

Notwithstanding the noisy nature of the data, some useful trends and patterns emerged. Hierarchical density based clustering identifies underlying patterns and dynamics in data that are often not discernible from visual inspection or intuitive. Nevertheless, hints of geo-cultural influences emerged from the clustering of outbreak dynamics across Nigeria, particularly if Clusters B and C are treated as offshoots of Cluster A. The states making up the clusters generally form a contiguous block linking to either Lagos or Abuja,the commercial and administrative capitals of Nigeria. Cluster D are mainly in the geographical middle of Nigeria, with the exception of Delta State. In addition, most Cluster E states are in a contiguous block in the South Eastern part of the country, with three exceptions. Also notable is the facts that most states in the cluster had late-breaking outbreaks, again alluding to hidden geo-cultural variables.

Elucidation of the full underlying factors responsible for the possible dynamic similarities requires further investigation, but the above-mentioned cluster patterns form a justification for such an endeavour. Very likely, the patterns may relate more to policy, mitigating strategies and cultural aspects of the response of the populations of those states. For this study however, the clusters might provide a qualitative backdrop to discuss the outbreak in each state. For example, Lagos and Ogun have both have more cases per capita than other states in Cluster A. In addition, the high population density of Lagos caused low adherence to mitigation strategies in the state. Other Cluster A states may therefore consider Lagos as a limiting case of their own outbreaks.

No correlations were found between the rate of outbreak spread and population density or distance from the primary international ports of entry. However, while the correlations with temperature and absolute humidity were both weak, they were statistically significant (p < 0.05). Numerous studies have found associations between COVID-19 spread and both temperature and absolute humidity. Contrary to the findings of the current study, previous studies have mostly found both high temperature and humidity having an inhibitory effect on the spread of COVID-19, for example, [18] , [30] , [34] .

Notably however, studies in tropical and sub-tropical countries are revealing slightly divergent results. In a study carried out in Jakarta, [27] , no correlation was found with humidity. A positive correlation was found with mean temperature (Spearman correlation coefficient of 0.392, p < 0.01). Another study in sub-tropical areas in Brazil found that correlations with temperature flattened above 25 0 . Furthermore, [2] provided evidence of positive correlation between COVID-19 spread and both high temperatures and intermediate relative humidity in tropical regions. This backdrop renders the findings in the current study more interesting, as they must be interpreted as additional evidence in an emerging thesis of differing effect of temperature and humidity in the tropics versus in cooler regions.

An important factor in this thesis may be the use of air-conditioning. Higher temperatures lead to more use of air conditioning and there is already some tentative link between air conditioner use and COVID-19 spread [17] . This in fact correlates with a common but anecdotal observation in Nigeria that a disproportionately high percentage of individuals who develop severe complications from COVID-19 are affluent or financially comfortable; a link between high temperatures and COVID-19 spread mediated by air conditioner use would be consistent with that observation. Further investigation into the effect of weather on COVID-19 spread in the tropics is recommended.

A number of revealing contrasts can be made between two pairs of neighbouring states. As the lockdown on movement was gradually lifted on both states, ρ increased before reducing for Ogun State (0.008 - > 0.009 - > 0.012 - > 0.0074 - > 0.011) whereas it reduced monotonically for Lagos, a neighbouring state (0.0095 - > 0.0064 - > 0.0034 - > 0.0036 - > 0.003 - > 0.001763561. This suggests that the lockdown was more effective in Ogun State, but not in Lagos. Consequently, the relaxed lockdown led to slight increase in the Ogun outbreak, which eventually slowed down.

Two other neighbouring states, Kano and Kaduna provide potent examples of effect of mitigation strategies on COVID-19 outbreak. The Kaduna State government was more decisive in enforcing lockdown, contact tracing, and in fact introduced travel restrictions that were stricter than any other state in Northern Nigeria. In contrast, the Kano State government implemented all of those measures in a more relaxed manner. As of August 10, 2020, the case fatality rates for Kaduna and Kano states are 0.74 and 3.3 respectively. This, despite the fact that both states are so close as to be indistinguishable on other important metrics. The two contrasts above and the weak or non-existent correlations with other factors suggest that mitigation strategies are the most important driving factors for the COVID-19 outbreak in various parts of Nigeria.

As shown in Table 1 , the outbreaks in at least 12 states using growth factor) or up to 22 (using R 0 ) are contracting, but the national outbreak is still expanding. The projection in Table 4 suggests a total of 519,672 confirmed cases by the end of the year, excluding Cross River and Kogi States. This however includes a somewhat surprising projection of 385,622 confirmed cases for Plateau State, largely due to the fact that Plateau happened to have one of the highest ρ (0.03) of any state on August 10, 2020, along with a low σ . There is nothing to suggest that such a high effective contact rate will persist for any significant length of time, but in keeping with other states, it was assumed constant for the whole of the simulation period. In addition, the case fatality rate for the simulation was low because many states had no deaths in their most recent phase by August 10, leading to values of κ at or close to 0.

There is a possibility of outbreak increase nationally due to the imminent lifting of all lockdown restrictions. While there is generally high compliance with face mask use and other guidelines in some states such as Osun State, compliance appears to be low in others such as Oyo State. Certain scenarios in a post-lockdown phase suggest that states will experience another expansion phase in the next few months. Of particular concern are social events such as wedding receptions in which jubilant and excitable large crowds converge within indoor environments. Such occasions make super-spreading more likely.

In order to predict a worst-case outcome by January 1, 2020, the SIRD models were simulated to that date again, with a higher value for r h o . Lagos has by far more COVID-19 cases per capita than any other state. In addition, its high population density makes lockdown restrictions more difficult to adhere to or enforce. The state has also had COVID-19 cases for longer, with more phases that any other state. Consequently, for a worst-case national scenario, the simulation was carried out with the highest value or r h o (0.011) recorded in Lagos at any point after the initial phase. This resulted in the predictions in Table X, with at least 14,785,457 confirmed cases. This is a high number, but the assumption that led to it is not incredible, since that same κ has been observed in Lagos during this same outbreak.

This study developed analysed COVID-19 outbreak data from Nigerian states and fitted SIRD models to them. Despite the noisy nature of the data, it is evident that the outbreak in Nigeria has been milder than initially anticipated, as is has been in some other tropical and subtropical areas. The finding of positive correlations between COVID-19 spread and both increased temperature and humidity is a surprising one echoed in a small number of previous studies, and underscores the need for more studies on the peculiarities of the COVID-19 outbreak in such areas.

Declaration of Competing Interest

The authors declare that they have no conflict of interest. No funding or financial assistance was received for this study.

Acknowledgements

The authors thank Mr. Tayo Badrudeen of Oduduwa University Ile-Ife, for suggestions during the formative stage of this study. The Titan Xp GPU in the workstation used for the study was kindly donated by the NVidia corporation.

Editor: DR B Gyampoh

Development interdependence: Locally driven, globally informed

Subscribe to the sustainable development bulletin, essay by: george ingram george ingram senior fellow - global economy and development , center for sustainable development viewpoints by: sarah rose , sarah rose senior advisor for localization - usaid rachel leeds , rl rachel leeds strategy analyst - usaid tariq ahmad , ta tariq ahmad senior policy advisor - millennium challenge corporation martha bowen , mb martha bowen deputy vice president for policy and evaluation - millennium challenge corporation meghan armistead , ma meghan armistead senior research and policy advisor - catholic relief services marin belhoussein , mb marin belhoussein policy lead, aid and development finance - oxfam gretchen king , gk gretchen king former localization advisor - oxfam larry cooley , larry cooley nonresident senior fellow - global economy and development , center for universal education john coonrod , jc john coonrod founder and chair - movement for community led development gunjan veda , gv gunjan veda global secretary and executive director (u.s.) - movement for community led development justin fugle , justin fugle head of policy - plan international claudia gonzalez , cg claudia gonzalez executive director - ensena por paraguay anna molero , am anna molero chief government officer - tech for all brianna guidorzi , bg brianna guidorzi policy analyst - near karl hofmann , kh karl hofmann president and ceo - population services international dylan matthews , dm dylan matthews ceo - peace direct vahe mirikian , vm vahe mirikian managing director - washington dc peace direct anthony f. pipa , anthony f. pipa senior fellow - global economy and development , center for sustainable development susan reichle , susan reichle ceo and president - international youth foundation ritu sharma , rs ritu sharma co-founder and president - women thrive worldwide cynthia smith , cs cynthia smith director of global initiatives - humentum william von schrader , and wvs william von schrader senior director, localization - save the children jenny russell jr jenny russell senior director of development policy and advocacy - save the children.

September 9, 2024

• 92 min read

This compendium of essays expands on the conversation from a roundtable hosted by the Center for Sustainable Development at the Brookings Institution on April 5, 2024. The event’s purpose was to generate a discussion on the role of international expertise and international nongovernmental organizations (INGOs) in a localization frame, a topic mostly absent in considerations of locally led development.

An initial essay by Brookings scholar George Ingram, serving as background for the roundtable, poses three framing questions:

• Is there a role for international expertise and entities in the localization frame, and if so, what is that role?
• Can USAID, other donors, and intermediary organizations create structures and operating dynamics that provide global experience and expertise in ways that respect and support local actors being in control of priority setting, design, and execution?
• In what ways can USAID modify its procurement processes to facilitate participation of local and national Southern organizations?

Because no one observer can represent the diversity of views on locally led development, and in order to broaden the conversation and audience beyond those at the April session, participants in the roundtable were invited to write follow-on commentaries on the topic.

This compendium can be read in its entirety or selectively, depending on the reader’s interest. Readers can access specific viewpoints by clicking on the authors’ names in the sidebar navigation menu at any time.

Opening essay

The first essay in this compendium is the essay by Ingram, updated to benefit from the roundtable discussion and subsequent feedback. It includes an addendum highlighting key ideas put forth during the roundtable discussion.

Concept of locally led development

The objective of locally led development is for national actors, including government, institutions, and citizens, to drive their own development. An outstanding issue in the path to localization is determining the appropriate role of external actors as they transition from a leading to a subsidiary role in development.  

The donor community has been on a two-decade trek to sort out the meaning and execution of local ownership—the concept that development is most effective and sustainable when it is driven by local stakeholders based on local priorities, local design, local execution, local monitoring, and local evaluation. The 2005 Paris Declaration on Aid Effectiveness was seminal in emphasizing the role of local ownership, interpreted principally as the national government. Intergovernmental debates evolved through the 2008 Accra Agenda for Action and the 2011 Busan Partnership for Effective Development Cooperation, which stressed, among other stakeholders, the role of local governments and civil society organizations.  

Much of the recent discussion on aid effectiveness has focused principally on local ownership. But the original Paris Declaration sets forth five interdependent principles that contribute to aid effectiveness, of which ownership, possibly the most essential, is but one—alongside alignment, harmonization, managing for results, and accountability. These principles remain a helpful guidepost, even as they continue to be updated. 1

The concept of locally led development is based on the shortcomings of traditional top – down approaches and the recognition that the agency of local stakeholders , a long with local management of resources , are what are most relevant . T he current laser targeting o n local ownership is an appropriate response to three-quarters of a century of development driven too often by donor priorities and perspectives and accountability to their own constituents , often at the expense of local priorities and perspectives. The shift is probably necessary to steer the supertanker -like operations of donors to a more locally driven dynamic .

The endgame

However, localization should not be seen as the destination. Nor is it appropriate for all circumstances, and it can be taken too far. While being guided by local voices and priorities is always essential, every country in the Global South is on a different development trajectory. For example:  

• Developing countries have a mix of capabilities to advance their own development and needs for external support.  
• Many countries are mired in conflicts, humanitarian crises, and fragility that impair locally led development.  
• Too many countries have governance that is predatory, non-inclusive, or non-responsive to the needs and priorities of citizens.  

In addition, in these contexts and others, international knowledge, experience, capabilities, and access can contribute to the diffusion of innovation and successful participation in a global political and economic order that positively affects development. And there are universal values—human rights, inclusion, gender equity, democracy—that the U.S. and other donors seek to advance and will not abandon.  

It is important to acknowledge that, despite localization being the focus in many dialogues on development, it is one of multiple steps along the development journey. Think of localization in terms of the related concept that self-reliance is not the economic endgame either. As far back as the 18th century, Adam Smith explained that trade and specialization surpass economic self-reliance in creating economic efficiency and wealth for the overall benefit of society.  

The endgame is inclusive economic, social, and political development that is owned by national and local stakeholders and built on the best of local and global knowledge and capabilities, best characterized as locally driven, globally informed.  

USAID’s targets

Take the case of USAID. Building on the path initiated by her predecessors, Administrator Samantha Power has made USAID a leading advocate for localization. Setting a hard target of 25% of “eligible” U.S. foreign aid being programmed directly to local organizations by 2025 is an appropriate goal to move processes toward the more ambitious 2030 target of 50% of all United States government aid being locally designed and implemented, an acknowledged innovation on how to measure locally led development.  

But fixed targets lead to hard questions:   

• What is the appropriate definition of what organization/program qualifies as “local”?   
• What foreign aid falls under the rubric of “eligible”?   
• What are the pitfalls of promoting “local development autarchy” (e.g., executing development programs without the benefit of global expertise and experience), and how can they be avoided?  
• What is the appropriate role of traditional international expertise and development implementers (INGOs, universities, companies)?  

In an interconnected world, it is difficult to define what is local and know how strict a definition is appropriate.  

Definition of local

USAID (a) has a definition of “local entity” that is subject to interpretation by each of its operating units (country missions and headquarter bureaus and offices), and (b) identifies categories of assistance “eligible” for direct funding to local entities on a relatively narrow base of all U.S. development and humanitarian assistance. Publish What You Fund ( PWYF) bases its calculation on (a) a stricter definition of local (local organizations with no connection to international actors) and (b) a wider band of USAID budgetary accounts. Compared to USAID’s calculation that in FY 2022 10.2% and in FY 2023 9.6% of its funding is going to local organizations, a sampling of country programs by PWYF and Oxfam using their more rigorous definition of local and a broader scope of eligible fundings, found about half that level going directly to local entities.   

The advantage of a strict, clear definition is it makes it easier to assess progress and accountability. The disadvantage is that it can miss important nuances. USAID’s practice of allowing each of its many operating units to determine what counts as local allows for nuance but permits inconsistent determination of what is local.   

The conundrum of a definition revolves around who is in control and how to determine that. This can be seen in a few examples (both real and conceptual) of existing organizational and program structures that may or may not be determined as local:     

• Local and national government.  
• A U.S. nonprofit running a USAID-funded program 100% staffed by local citizens whose function is to respond to technical assistance requests from a government ministry.  
• A U.S. nonprofit, most of whose senior staff (VP level) are non-U.S. citizens resident in developing countries and whose function is to provide finance and other support to indigenous organizations, and with a third of the board from the Global South.  
• A regionally based NGO governed from and works only in developing countries—may be characterized as a “Southern-led INGO”.  
• An international nonprofit that is a federation of independent, sovereign national organizations.  
• A global consulting firm that is a network of independent national entities governed by the collection of Northern and Southern partners, sometimes with Southern partners in the majority.  

These examples are mostly locally or regionally managed with a level of global input.

Role of international expertise

In the ongoing debate among USAID and its implementing partners, and within the broader development community, both in the U.S. and globally, as to the appropriate role of those international implementing entities, it is useful to identify what the role of international actors might be in supporting local actors in a localization frame. What are the functions of international expertise and implementers that are relevant to a local/global dynamic, and how can they perform a supportive rather than a controlling role? Possibilities include:  

• Share knowledge and experience from other countries and communities.  
• Provide access to global networks.  
• Serve as a mediator between local stakeholders.  
• Provide political coverage or protection for local stakeholders.  
• Strengthen capacity.  
• Convene partners and stakeholders, local and global.  
• Help access funding.  
• Provide administrative functions required by donors (i.e., back-office functions such as financial accountability, risk management, and reporting and compliance functions).  

This mental walk-through of why and how international expertise and entities can contribute to locally led development occurs in a frame of broader questions that are almost philosophical in nature. The answers to these will be driven by context, values, and worldview. But there are higher-order questions that must be addressed first:  

• What does success in localization/locally-led development look like—sustainability, cost effectiveness, efficiency, best use of donor resources?  
• What do we mean by “local”—national government, local communities, women’s groups, NGOs, companies, individuals?  
• Different identification of who or what is “local” may depend on the circumstances and objectives.  
• Who determines who or what is “local”?

3 framing questions

The central issue of this essay is to consider what role international actors should play in the pursuit of successful development localization. The topic has received inadequate attention and would benefit from explicit discussion among local stakeholders, donors, and implementers. In particular, three specific issues need to be addressed:  

• Is there a role for international expertise and entities in the localization frame, and if so, what is that role?  
• Can USAID, other donors, and intermediary organizations create structures and operating dynamics that provide global experience and expertise in ways that respect and support local actors being in control of priority setting, design, and execution?  
• In what ways can USAID modify its procurement processes to facilitate the participation of local and national Southern organizations? 2

April 5 Roundtable Discussion—responses to the three framing questions.

Below is a summary of the ideas put forth during the roundtable in response to the three framing questions at the end of the essay. The conversation was robust and focused principally on the three framing questions. The views expressed were as diverse as the participants, with an overall perspective that there is a role for international actors in a localization frame, that power and control have yet to be effectively handed over, and lots of ideas but no consensus on the most effective way to accomplish that.

Question: Is there a role for international expertise and entities in the localization frame, and if so, what is their role?

• Fund Raiser: Mobilize resources for local organizations.
• Convenor: Provide a venue for dialogue between local organizations, INGOs, and funders.
• Networker: Connect local organizations with INGOs.
• Knowledge broker/Interpreter: Translate and interpret donor requests and requirements to local organizations.
• Trainer/Coach: Strengthen knowledge and capabilities in technical areas of development.
• Capacity builder: Strengthen capacity in areas of human resources, leadership, and responsiveness to local needs and priorities.
• Intermediary: Serve as the go-between for local organizations and international funders, specifically for local organizations not capable or desirous of direct relationships with international donors.
• Advocate: Represent Southern voices in international networks and dialogues.
• Proposal writer: Assist with proposals to international donors.
• Defender: Serve as a shield for local organizations from local political pressures.
• Mediator: Mediate among local organizations and with international entities.
• Administrative supporter: Provide back-office support to meet donor administrative requirements.

Question: Can USAID, other donors, and intermediary organizations create structures and operating dynamics that provide global experience and expertise in ways that respect and support local actors being in control of priority-setting, design, and execution?

Key recommendations included for USAID to:

• Provide funding to cover the full overhead expenses of local organizations.
• Translate proposals into multiple languages.
• Hold convenings in the South and in places that do not require a visa.
• Create standards and norms to manage risk and minimize inherent risks to local organizations.
• Avoid implementing organizations co-opting the localization agenda (e.g., nationalization of country offices, decentralization of power from headquarters).
• Extend funding through locally trusted intermediaries (like the United Way).

Question: In what ways can USAID modify its procurement processes to facilitate participation of local and national Southern organizations?

• If there was one overarching point, it was that if the funder requires funding in a certain fashion, the implementer will comply.
• Make local partners the default. Require documented rationale for why international actors are operating without a local partner.
• Provide more transition awards.
• Include funding for capacity strengthening of local organizations.
• Provide standalone and integrated capacity-strengthening awards.
• Make local organizations the prime applicant and the international implementer responsible for financial due diligence.
• Move more funding through grants, thereby reducing the administrative/reporting requirements.
• Include handing over the power of projects to local organizations as a required deliverable.
• Measure against local capacity strengthening best practice indicators.
• Separate the sub-contractor and prime relationship at the point of the award.
• Change the program cycle to include the whole systems strategy development with international and local stakeholders participating in the development of the strategy. Then fund organizations, people, and partnerships rather than projects.
• Require exit strategies for development and humanitarian assistance.
• Provide funding for INGOs to serve as the convener of local organizations for project co-development.
• Restrict solicitations only to local actors, excluding ones that are deemed affiliates.
• Reduce the administrative paperwork, including simplifying periodic reporting.
• Hold the local grantee against its own objectives, not the donor’s package of indicators.
• Build in accountability to local stakeholders.

The following essays were authored by participants who accepted the invitation to present their own perspectives and experiences. The authors include U.S. government officials, representatives of U.S. and Southern civil society organizations, and individuals with experience in development.

Particularly noteworthy are the first two essays by senior staff of the U.S. Agency for International Development (USAID) and the Millennium Challenge Corporation (MCC), which lay out how those agencies see the role of international entities in locally led development.

Additionally, the essays by development practitioners, especially by Southern voices—which must be central to this topic—provide important perspectives from their experience in implementing localization.

The role of international partners in advancing locally led development

USAID’s localization efforts build upon many years of past efforts and lessons learned around promoting local ownership. Many of these lessons inform how the agency understands the role of international partners—including INGOs, large and small development contractors, faith-based organizations, and United Nations agencies—in advancing locally led development.

One fundamental lesson relates to the rationale for locally led development. For years, the international community has considered local leadership and ownership over goals and processes to be critical for effective programming and sustained results. While there is still broad consensus on this point, the motivation for locally led development has expanded to include a focus on equity, with greater inclusion of the people and communities affected by the aid system. Shifting power requires rethinking everyone’s roles and practices, including those of international partners.

A second, related lesson pertains to how USAID frames its localization goals. In the past, the agency has emphasized direct local awards as the main way to advance localization and track its progress. Now, with more emphasis on shifting power, USAID is also examining how it creates opportunities for local actors to exercise influence over development programming. Control of resources is an important form of power, but local actors can also exercise power in other ways: setting the agenda; developing solutions; and bringing their capacities, leadership, and resources to bear to make those solutions a reality. International partners have an important role to play in creating opportunities for these types of local leadership and in supporting the broader development and humanitarian assistance community in being responsive to those locally identified priorities and solutions. 

Drawing upon these lessons, USAID has reaffirmed its commitment to shifting funding and decisionmaking power to the people, organizations, and institutions that are driving change in their own countries and communities. Since 2021 , USAID has been working toward two agency-wide localization targets: 

• To channel a quarter of USAID funding directly to local partners. 
• To ensure that, for the majority of USAID programs, local actors are in the lead for project design, implementation, and results measurement. 

While USAID’s direct local funding target often gets more attention, the local leadership target is equally important. And it is to this goal that international partners can make valuable contributions. 

The (many) opportunities for international partners to advance locally led development

International partners can help shape international systems, including the aid system, to be more inclusive of local actors. They can support local actors’ integration into international networks and markets and facilitate coordination and collaboration between donors, INGOs, and local actors. They can contribute evidence on the impact of locally led approaches and help advocate and mobilize resources for locally led development. 

In their work with local actors, international partners can collaborate, learn, and adapt with local stakeholders throughout program implementation, for example through accountability and feedback mechanisms . They can bring local actors into co-creation processes during design and implementation. 

International partners can fund subawards to local organizations in ways that elevate local leadership . They can view their relationships with subawardees not just instrumentally, as a way to deliver specific elements of a program, but as an equitable partnership that aims to strengthen the broader local system. They can strengthen local subawardees’ organizational health by budgeting to support their full cost recovery (for instance, by implementing the revised federal regulations , effective October 1, that permit a 15% indirect cost recovery rate for subawardees). International partners can also serve as subawardees in support of directly funded local partners. 

International partners can also engage in valuable capacity strengthening , mentoring, and coaching of local organizations, building on their existing strengths and supporting them to achieve their goals. 

The international partner community is having important conversations about its role in advancing localization. INGO leaders are emphasizing locally led development and identifying the changes their organizations can make to advance these goals. Some INGO boards are paying increased attention to their organizations’ localization efforts, alongside other elements of organizational health. Movements like the RINGO Project (Re-Imagining the INGO and the Role of Global Civil Society) and the Pledge for Change are providing spaces for international organizations to think and talk with Global South-based organizations about what it means to form more equitable partnerships with local actors. 

USAID’s enabling role

USAID also has a role to play in encouraging and shaping the nature of relationships between international partners and local actors. The Agency recently revised its operational policy on the program cycle to set expectations for staff to integrate local knowledge and local leadership across strategic planning; program design; implementation; and monitoring, evaluation, and learning processes. To guide efforts to integrate local leadership into its programs, USAID has developed tools and resources, many of which are relevant to international partners. Some are broadly applicable, like the locally led development spectrum and checklist tool . Some are sector-specific. For example, the Bureau for Democracy, Human Rights, and Governance (DRG) produced a series of papers outlining the shifts that better elevate local leadership and support more effective rule of law , civil society , and governance programs. And the Bureau for Resilience, Environment, and Food Security (REFS) published new “ Localization Activity Design Guidance ” for activities related to Feed the Future initiative. 

USAID is starting to be more intentional about understanding the ways its programs create space for local actors to exercise leadership. In 2023, the agency developed and piloted a new “ locally led programs indicator ” that tracks the extent to which programs utilize, over the lifespan of an award, a range of “good practices” that advance locally led development, including listening tours; co-creation; local subawards; participatory monitoring, evaluation, and learning processes. A new USAID report, “ Committed to Change: Localization Progress Report FY 2023 ” , discusses the results of the pilot, as well as some adjustments the agency is planning to make to the indicator. Forthcoming changes will streamline and clarify what the metric seeks to measure and reflect greater ambition for what it means for a program to demonstrate commitment to local leadership. 

A role for everyone, grounded in values

The development and humanitarian ecosystems are made up of a wide range of actors. The central objective should be to leverage and build upon the unique expertise, resources, knowledge, skills, and networks of all actors in a manner that creates or supports the conditions for local actors to exercise their leadership. Those conditions are predicated on relationships based on transparency, listening, trust, mutuality, and respect. Attention to these values, by donors and international partners alike, can help build a more effective, inclusive, and equitable aid system.

Lessons from MCC: Implementing local ownership

In bilateral development partnerships, the Millennium Challenge Corporation (MCC) adopts a relatively unique operational model. MCC programs work with international contractors but under the authority and management of local stakeholders, which include representatives from the partner government, civil society, and the private sector. The model is an example of the question posed by George Ingram in the opening essay—can donors “create structures and operating dynamics that provide global experience and expertise in ways that respect and support local actors being in control of the priority setting, design, and execution”.

MCC’s operationalization of country ownership has three tangible dimensions: countries determine the investments, implement the programs, and are held accountable by their domestic stakeholders.

Countries control the prioritization process: Once eligible for MCC compact or threshold assistance, partner countries choose the sectors where MCC invests, based on an economic analysis of the countries’ key constraints to economic growth and informed by meaningful engagement with citizens, civil society, the private sector, and other donors. MCC and partner countries then work together to design investments that meet country priorities, are cost-effective, and have strong potential to reduce poverty through economic growth. MCC does not set out to focus its investments in any specific sectors.

• Countries implement their own programs: MCC has small in-country missions in program countries (typically only two U.S. direct hires). MCC requires partner country governments to establish accountable entities to lead program implementation. These entities, typically established by law or other formal instruments and known as Millennium Challenge Accounts (MCAs), are led, managed, and staffed by country nationals and work directly with existing government ministries and other domestic stakeholders.
• Countries are accountable to domestic stakeholders for results: Each MCA reports to its own board of directors (or similar governing entities), including ministerial officials and representatives of the local civil society and private sector. Thus, MCA boards are accountable to national governments and their citizens for the implementation of MCC-funded programs, transparent decisionmaking, and achieving results.

Notwithstanding how country ownership is operationalized in MCC’s model, as described above, the reality is that there are only a few entities, usually based in the Global North, that can build infrastructure at the scale required by MCC-financed programs or address specific due diligence requirements.

The uniqueness of MCC is characterized in two specific ways . First, the programs being implemented by international entities were codesigned with government counterparts. Second and more important, the local accountable entity, the MCA, selects the implementing contractor and oversees its work—i.e., the MCA is the client. The MCA performs procurement and contract management functions for implementing their programs—meaning they are at the helm of decisionmaking and monitoring the performance of the international (or local) entities they have selected to implement planned activities. This separates the MCC model from other donors’ models through a commitment to provide more authority and control (and thus, more power) to country counterparts. To illustrate: When MCC says it is providing a 345-million-dollar grant through a compact with Malawi, as we did in 2011, Malawians managed 100% of that money through their locally accountable entity.

There are some important nuances related to the degree to which the MCA can localize or fully manage the procurement process. First, MCC’s “ Program Procurement and Grant Guidelines ” ensure that MCA-conducted procurements are done through international competitive bidding. There is no American preference and no local preference. Second, once the required procurements have been identified and a procurement plan approved by the MCA board, they must submit key documents to MCC for “no objection” before proceeding with procurement. In other words, while the MCA performs the work, there is an accountability structure in place that is responsive to MCC’s requirements and standards.

Recently, MCC has undertaken an exercise called Procurement@20 aimed at shifting an even greater degree of ownership and responsibility for the procurement process to MCA partners. These reforms reduce the number of MCC touchpoints during the procurement process and optimize the role of the MCA Board of Directors in procurement oversight. On average, internal assessments suggest that the Procurement@20 reforms will reduce procurement timelines by 30%. These changes grant MCAs more authority and more accountability for ensuring quality procurements while also saving time.

Furthermore, MCC is undertaking an exercise to explore ways to deepen its commitment and implementation of country ownership and locally led development. This effort aims to pursue and reinforce principles at the heart of locally led development: more local ownership over priorities, implementation, and resources. The goal is to support development leaders to pursue development in the ways local partners see fit.

This review includes conversations across the MCC and within civil society. Most importantly, this review includes discussions with our MCA colleagues who know what it will take for MCC to support their ability to deliver MCC programs in close consultations with their local stakeholders.

We ask external audiences to pay attention to MCC efforts and keep the organization accountable to its commitment to country ownership and locally led development.

At the end of the day, donors such as the MCC don’t “do development.” Instead, the governments, their people, companies, and civil society are at the helm of solving their development challenges. MCC hopes to partner in a manner that supports its leadership. And ultimately, we hope the agency’s model, and what has been learned from 20 years of experience can be a successful approach from which other donors can learn.

An aid system of subsidiarity and solidarity: Centering local institutions, investing in quality partnerships

The development and humanitarian needs around the world in 2024 are daunting, and the aid system will require robust and effective responses from all stakeholders to meet global challenges. As an organization rooted in Catholic Social Teaching, Catholic Relief Services (CRS) centers its work on the ideas of subsidiarity and solidarity. Subsidiarity requires acknowledging that those closest to a challenge are often best positioned to identify a response and that all people have the right to be the authors of their own future. As such, one must look to local development and humanitarian institutions as expert voices on community and national needs and essential leaders for effective solutions. Solidarity calls on everyone to stand together with sisters and brothers around the world to support these solutions and to work together toward a world free of poverty and injustice, and in a way that respects the dignity of all people.

The drive for a more locally led future: Progress, and much left to do

These organizational values, as well as experience working in partnership with thousands of local organizations, lead to ardent support for the movement for more locally led development. It has, therefore, been heartening to see growing support for localization efforts in recent years from donor agencies, Congress, peer agencies, and other stakeholders. As George Ingram’s opening essay notes, the need for local leadership in development and humanitarian efforts is now widely recognized.

However, while it is important to recognize the increased attention localization has received and to celebrate policy progress (such as USAID’s Local Capacity Strengthening Policy , and recent changes in the “ Assistance and Acquisition Policy ”), it is equally important to be clear-eyed about where progress has stalled. Reflections on the roles of local and international actors in the aid system must be rooted in current reality. They must take care not to fall victim to outdated tropes or misperceptions.

Currently, nearly all donor resources and decision-making power remain in the hands of international actors. Despite ambitious targets, international entities still receive over 90% of USAID funding (see Publish What You Fund’s research , which indicates it is closer 94.3%). On the humanitarian side, USAID’s Bureau for Humanitarian Assistance has reported that 99% of its funding goes to international actors. Localization efforts are, of course, about more than just funding. But leadership opportunities and significant decision-making roles remain elusive for local actors as well. As the Movement for Community-led Development notes in a recent open letter , there is “longstanding frustration by many local leaders [about] being effectively excluded from international conferences and meetings about locally-led development”, and this frustration is mirrored at policy tables, coordination mechanisms and policy dialogues. Given this reality, any argument that raises concerns about localization going too far should be approached with great wariness.

Similarly, despite some assertions to the contrary, in reality, there should be no lack of clarity around localization’s objectives nor confusion that localization of aid is the end goal. Poverty alleviation, effective and just development, and effective humanitarian assistance are the goal. The political question at hand is merely if the aid system is ready to realize a shift in power and move beyond assuming that international organizations are the only stakeholders ready and able to lead any part of the process.

Aid stakeholders’ changing roles

As the aid world has increasingly recognized these twin needs for both local leadership and global partnerships and solidarity, the debate has not been about whether global actors have a role to play but rather how each stakeholder can most effectively have the greatest development impact. Much has been written in recent years about the future roles, and potential impact INGOs can have in a changing aid system, including the Grand Bargain’s caucus on the role of intermediaries , Peace Direct’s “Nine roles intermediaries can play in international cooperation”, George E. Mitchell, Hans Peter Schmitz, and Tosca Bruno-van Vijfeijken’s “ Between power and irrelevance: The future of transnational NGOs ”, and the body of work coming out of the RINGO project . Throughout all of them, there is a clear consensus emerging that stresses the need for INGO adaptability and increasing their capacity to take greater intermediary roles such as technical assistance provider, process facilitator, advocate, solidarity partner, network supporter, etc.   

Many INGOs have seen the powerful impact taking on these kinds of roles can have for local partners and communities, and for development outcomes. The biggest challenge for INGOs to take on these roles more robustly is the current INGO operating model and the lack of available resources to transform it. As long as INGOs are funded only to directly implement projects, ceding leadership to local actors and taking on new more intermediary roles will remain challenging. The most direct way to help INGOs transform is for donors to change what they fund.

Partnerships between local and global organizations can be effective. Whether via the United States President’s Emergency Plan For AIDS Relief (PEPFAR) transition awards that have helped local organizations transition from sub to prime implementer of large-scale health programming, or through the High-Performing Implementers (HPI) Initiative where targeted solutions packages have helped national governments transition into principal implementers of Global Fund awards, or through the EMPOWER program , where demand-driven capacity investment and support result in local partners leading increasingly complex emergency response, INGOs can play a helpful role in advancing locally led development. However, too often these roles require self-funding, as they do not line up with donor funding opportunities.

If donors like USAID want INGOs to play more effective intermediary roles, their action must go beyond policy change and look firmly to resources. Specifically, USAID should consider:

• Ensure adequate funding for effective, holistic, demand-driven capacity strengthening in line with its Local Capacity Strengthening The policy’s principles are powerful and hold the potential for transformational organizational change. However, its impact is directly correlated with the resources that are available and allocated for its application. Whether through stand-alone capacity-strengthening programming, or capacity-strengthening efforts that are integrated in key sectors, USAID must ensure that its level of investment in local organizations is aligned with its locally led development vision.
• Increasing, expanding, and strengthening transition awards. PEPFAR has shown that transition awards can be powerful mechanisms for local organizations to grow into new leadership opportunities and for INGOs to play an effective part in advancing that process. Their success should be built upon, and their use should be
• Supporting effective, trust-based equitable partnerships. It is well-documented that effective localization processes are often rooted in quality partnerships. CRS has found that the strongest partnerships are rooted in mutuality, trust, transparency, and commitment. However, too often, the time and resources required to support these relationships do not line up with procurement and grants management processes. USAID should ensure that partnership activities (identification, co-creation, strategic collaboration) that support effective capacity-strengthening and transition processes are also adequately supported and resourced.
• Prioritizing accountability, including by tightening the definition of local actors and ensuring meaningful metrics: It matters what type of institutions are able to take advantage of newly dedicated localized funding vehicles and local actors (see the NEAR network’s paper on definitions) and the international community (see IASC’s position on definitions ) have been clear on what the parameters should be. A fair playing field specifically for local institutions to access funding is critical. It is not helpful to include misleading categories like “locally established” entities in the target group for access to localization funding if or to have a definition of “local entities” that includes international subsidiaries. Doing so will undermine policy goals.

Transforming the aid system is not easy, and there is much left to do. To be effective, donors and policymakers should focus on centering local leaders and their institutions, leveraging and strengthening quality partnerships, and supporting global stakeholders to adapt, all in the service of effective, efficient, sustainable and just development.

Continue to ask local actors what the role of INGOs should be

What role would local actors like INGOs to play in the humanitarian and development system? It is a question that INGOs should continuously ask local partners, other local organizations in the operating context, and representatives of local and national institutions, including government officials. While there will be myriad responses, common themes likely will emerge based on the sector, geographic location, and capabilities of the INGO doing the asking.   

For example, Oxfam Pilipinas undertook a process to explore its role in the humanitarian and development sectors in the Philippines as it became a national organization and the country affiliate of Oxfam International. As a result, within the country, Oxfam Pilipinas will now focus its own localization agenda on localizing knowledge, decision-making spaces, and money. This will mean working to see local actors more substantively involved in the creation, diffusion, and articulation of knowledge; greater representation of local actors in spaces of discourse, debate, contestation, and decision-making; and greater access by local actors to development funds. These steps will have implications for Oxfam Pilipinas’ operating model, core competencies, and leadership role within the country.    

In a different country context, partners in Iraq see an important, specific role for INGOs in their influencing capacity. A 2020 Oxfam America report described a local NGO’s  perspective, “There is still a huge need for international actors, both for funding and capacity building. And the pressure they bring by shedding light on things has more impact than if locals shed that light. The watchdog role is real. If the internationals pull back, the checks and balances disappear.”    

These two examples illustrate why it’s so important to ask local actors what they need in their context and that a “one size fits all” approach to the changing role of INGOs will not work. Donors, including USAID, also should continue to increase their engagement with local actors to design activities and awards that are responsive to local priorities and have local organizations implementing them. Out of that process, INGOs can then plug into where those locally driven projects need their support—not their leadership.   

Fortunately, USAID has been creating tools and guidance for years to ask local actors what is needed and how to address challenges in their communities. These tools and guidance can be the building blocks for further clarifying the roles of INGOs and local actors in a specific context. For example, USAID’s  “Whole Systems in the Room” (WSR) is “an approach that brings together as many different stakeholders as possible, often in an intensive workshop, to strengthen relationships, to learn from each other’s perspectives, to build consensus and identify solutions to development problems they are facing, and commit to collective action” (USAID, Toolbox of Empowerment , 2022). Co-creation resources abound for use by Missions and implementing partners, as do Collaborating, Learning, and Adapting resources. Finally, the Locally-Led Development Spectrum and Locally-Led Development Indicator also provide opportunities for gaining greater clarity on new roles for INGOs seeking to change power dynamics within the aid system.   

Donors also must directly fund local organizations beyond current levels. Approximately 90% of USAID funding still goes to INGOs, international for-profits, and universities (USAID, Localization Progress Report , 2023). This must change. Local actors should be leading the response to humanitarian and development challenges. Donors have incredible power to shape the aid system and create incentives by choosing who and what to fund; specifically, donors should be funding local organizations to spearhead responses and INGOs to provide specific support. Therefore, it matters how donors define and differentiate between local stakeholders and INGOs.  

Unfortunately, several donor definitions of “local,” including the one USAID has adopted for its current localization agenda, do not make a clear enough distinction between local organizations and INGOs. The current definitions leave significant room for international organizations with offices around the world to receive funding as “local” entities. This issue is apparent in the underlying data from USAID’s 2022 and 2023 Localization Progress Reports, among other sources. For example, recent research by Oxfam and Publish What You Fund on USAID funding to development and humanitarian assistance organizations has demonstrated that USAID’s current localization initiative would benefit from a stricter definition of a local entity by excluding affiliates connected to INGOs.   

Ultimately, there is a need for the unique contributions of local partners, INGOs, and donors given the nature and scale of today’s humanitarian and development challenges. But if the sector is serious about having the individuals and communities most affected leading in the design and implementation of responding to these challenges, INGOs and donors must systematically ask local partners what role they would like INGOs to play and then create incentives and funding structures that enable each stakeholder in the system to embrace their new role.

Examining the links between localization and scaling

There are two compelling and complementary arguments for localization—one rooted in morality, politics, and history; and the other, an instrumental case, rooted in development practice. While each of the two arguments has merit in its own right, this essay focuses on the instrumental case for localization—specifically, the link between localization and achieving sustainable outcomes at scale.

Since 2015, I have co-led the Scaling up Community of Practice (SCoP) that has 4200 members from more than 400 organizations in 70 countries. Approximately half of the SCoP’s members and organizations, and a growing portion of its leaders, hail from and reside in lower- and middle-income countries. The SCoP operates 10 working groups focusing on scaling development, climate, and humanitarian outcomes in a range of sectors and settings. Three of the most important insights from that work are: (1) with few notable exceptions, only governments and commercial markets have the capacity and incentive to deliver goods and services sustainably at scale; (2) transformational scaling involves permanent change in country-level systems and institutions; and (3) the time required for an effective transition to scale innovative products, services, and practices is rarely less than a decade.

Given these realities, successful scaling is almost impossible if it is not driven, led, funded, and provided by effective local institutions with the needed reach, capacity, source of funds, and staying power. Official development assistance (ODA) and private philanthropy—often delivered through time-bound, one-off projects that collectively represent a small share of the recurrent budget in many sectors and countries—are significant only to the extent they support, foster and enrich these permanent, place-based, demand-driven institutions and solutions. Simply said, no meaningful localization means no sustainable scaling.

The “sustainable outcomes at scale” argument for localization has implications for the nature of localization as well as its importance. For some, “local” means community level. For others, it means national. From the scaling perspective, national trumps local, with community-level interventions necessarily accompanied by the need for a realistic strategy for reaching very large numbers of communities. Likewise, from a scaling perspective, the first priority goes to those local institutions with the capacity and incentive to achieve development, climate, and humanitarian outcomes over time and at scale. That usually means focusing first and foremost on national and sub-national governments, linked where appropriate with major local private sector actors and key local intermediary organizations like universities, banks, and think tanks. The important exception to this is cases where these institutions are unreliable stewards and partners, but even here, the bias should be to support their reform rather than their subordination.

Fragile states are a special case because of the outsized importance of foreign assistance and the challenges posed by predatory governments, disputed legitimacy, or underperforming institutions. In these countries, people often view issues through the prism of underlying grievances, and the selection of local partners can easily have the unintended effect of exacerbating rather than mitigating these tensions. The reverse is also true. Conflict-sensitive actors and engagement strategies can sometimes provide important secondary benefits in addressing a conflict’s underlying drivers. In either event, localization is not conflict-neutral, a reality that takes on particular importance in a world where fragile states are the recipients of U.S. and global foreign assistance.

Finally, the scaling perspective has implications for the choice of local implementing partners since those organizations ideally constitute important parts of the local institutional infrastructure. A competitive assortment of effective, country-based service delivery, policy analysis, and advocacy organizations, private firms, NGOs, think tanks, and public institutions play a central role in most wealthy countries, and the strengthening of these institutions should be an important priority in emerging economies and newer democracies. That requires organizations that are built-to-purpose for local markets and requires a willingness by host governments and others to engage those institutions through grants and contracts. Foreign aid can help catalyze the evolution of this set of institutions by using them in a way that facilitates and stimulates their broad use by a host country’s government agencies and other established institutions including, but not limited to, external donors. Thus, according to insights from the SCoP,  anything that supports positive movement in that regard is progress. Anything that works against the growth of a dynamic and competitive array of local public and private institutions able and willing to serve an array of domestic clients is inadvertently a step in the wrong direction.

The potential roles of international funders and implementers are significant but not central in supporting the needed changes in policy and practice. On the funding side, while external resources are small relative to the size of most problems and tend to be time-bound, they often have outsized influence when they provide the bulk of the discretionary resources needed to introduce and scale new practices. Used properly, they can materially advance sustainable scaling. Likewise, when they are inattentive to the dynamics of long-term change, they can seriously distort the incentives and strategies of local actors.

During funding implementation processes, U.S. and other international partners can play important roles as well. To mention four:

• Where necessary, most obviously in fragile states, external third parties are often able to position themselves as independent actors for key analysis, convening, intermediation, and fund management activities.
• In countries where there continues to be a shortage of local organizations able to meet donors’ rigorous standards, international partners can play a capacity-building role and/or shelter local actors from some of the more idiosyncratic donor requirements.
• In countries where there is not yet a strong competitive market for local analytic and implementation services, donors can help to seed that market and showcase its utility.
• International partners can help establish linkages for host governments and other local organizations with global expertise and with relevant organizations in the U.S. or other countries.

To contribute to sustainable outcomes at scale and effective localization, it is essential that these external funding and implementation roles be designed and performed with an explicit eye to enhancing, not substituting for, the capacity of organizations with local legitimacy and permanent national presence to occupy center stage and to perform each of these functions over time.

As the opening essay and the subsequent roundtable discussion illustrate, these and other lessons are being learned and shared in real time and at warp speed. I am genuinely excited to know what the conversation will sound like the next time we convene.

Embracing locally led approaches for equitable and effective outcomes

Locally led development is a process of transforming the current system to a more equitable one where those closest to an issue decide how it should be addressed and do so with the support of allies. Such a systemic transformation requires the engagement of multiple stakeholders, including communities, community-based and local organizations, local governments, entrepreneurs, funders, and international civil society. Indeed, most local organizations do not want INGOs to disappear. What they seek are equitable, trust-based partnerships where their knowledge, lived experience, and leadership are recognized and supported. Thus far, local actors have been squeezed for resources and forced to follow expert guidance from external actors, often against their better judgment. William Easterly’s “Tyranny of Experts” illustrates how that notion of expertise has not only been a tool of dominance but an often misguided one.

The Minority World (typically called the Global North) needs to develop greater expertise in listening, fixing the deep inequities in the global development system and supporting the wealth of local expertise in the Majority World (often referred to as the Global South). Minority World entities have to support more Majority-World experts to take the lead in all relevant research and policy analysis. Locally led development is about centering the expertise of communities and local organizations, ensuring they have the power and resources to design and implement solutions, and recognizing their ownership over these solutions.

INGOs and Minority-World actors have a role to play in locally led development. They can use their influence and reach within their own countries to amplify the voices and demands of local actors. They can also dispel myths around corruption, lack of trust and capacity of local entities, which are grounded in patterns of colonialism and structural racism. They can protest budget cuts by bilateral agencies, advocate for greater cost recovery for local organizations, well-being funds, and contingency budgets. Minority World actors can also serve as facilitators, connectors, and interpreters; funder rules and guidelines are almost always impossible to decipher, particularly when they are in foreign languages (like English or French).

The report on “The nine roles that Intermediaries can play in international cooperation” by Peace Direct provides a good starting point for Minority World actors to re-examine their roles in a locally led ecosystem in the spirit of solidarity and humility. However, what local organizations seek are not intermediaries but allies. Participants in the April roundtable frequently spoke in terms of the ecosystem that supports locally led and community-led development. USAID and others must focus on investing in ecosystems that center grassroots communities and build outwards.

What is called for is a radical commitment to “local first” in all development activities, including systems thinking and strategy design—not just priorities and implementation. In situations of poor local governance and fragility, as noted in George Ingram’s opening essay, it is actually local actors and their networks who would be best placed to undertake a systems analysis and decide how to address those challenges in the fragile environments where they work. If local actors desire external perspectives and references, they can seek out sub-regional bodies or other Minority-World actors. The role of INGOs in these situations is to support and provide information and capacity strengthening as and when requested, without overshadowing the agency and leadership of local actors.

For communities to thrive, there must be a well-financed and responsive first tier of government able to work in effective partnership with grassroots civil society. Strong local governance is a key pathway to sustainability, and it has largely been ignored and starved for resources and decision-making autonomy.

Civil society thrives and can scale up its impact when it can operate within inclusive and resourced networks from both local and global funders. Are there intermediary funding institutions that can channel and steward larger governmental, philanthropic, or ODA resources to hundreds of community-based organizations in a manner that is responsive to their needs (timing, payment modalities, size of grants)? In many countries, this is largely missing. And yet, there exist, within almost every Majority-World country, local networks of organizations that can play this role with support and resources.

USAID has taken important initial steps in becoming more accessible, with translations, a simplified website, transition grants and increased audit thresholds and per diems. One of the biggest obstacles to realizing locally led development, however, is competitive processes. The challenges of development require a whole-of-society approach that facilitates all able and willing actors to work together, not a system that makes local organizations compete with each other for scarce resources.

Decentralized development in health, education, livelihoods, etc., can be tackled the same way one would plan polio vaccinations: put the money up first, then invite various stakeholders (local government, local civil society, community leaders) around the table at the district level with a good map, align on targets and distribution of activities and means of reporting. Currently, this is done in reverse—competing consortia are formed, almost always led by INGOs or large private contractors who come up with plans with their own money; local organizations have neither the time nor resources to compete in such processes. This situation is further compounded when country offices of international organizations begin to bid in funding for local organizations.

Funders like USAID can play a vital role in transforming the development and humanitarian systems to make them more locally led. They can do this not just by providing more direct, flexible, robust, multi-year funding to local organizations but also by putting in place measures that require all implementing organizations to put communities in the driver’s seat in their programming, from planning to design, implementation, and evaluation. The measures USAID is taking to increase the de-minimis rate for indirect costs to enable cost recovery for local organizations are noteworthy. However, as long as these measures remain optional, international actors may continue to starve local organizations of much-needed operational capital to make their proposals more competitive. Similarly, co-creation can become a highly extractive exercise unless it comes with adequate compensation for the time, knowledge, and leadership of communities and local organizations.

USAID can take the following steps to not just become more locally led in its approach but to strengthen the local ecosystem:

• Ensure that the policy measures being taken to support local organizations (such as the increase in de-minimis rate for indirect costs) and community leadership (such as co-creating with community members) are implemented by Minority World actors, making funding conditional on performance on these measures.
• Strengthen and fund local and regional networks – these networks are composed of local organizations and can, therefore, channel funding directly to them in ways that are suitable to their needs. They are more accountable to their membership than any external intermediary and work on the principles of collaboration, not competition.
• Fund and support new organizational structures based on power sharing and equitable partnerships, and innovative initiatives that strengthen the local ecosystem.
• Make provisions for pre-award costs to be reimbursed through mechanisms like design phase funding and paid co-creation.
• Create and maintain spaces for direct interaction with local and community-based organizations to understand how they are experiencing USAID policies and calls for proposals and how the systems can be tailored to their needs.
• Continue to take steps to ensure language access and total cost recovery for local organizations.
• Invest in programs that strengthen local government institutions and their capacity to work with communities.

USAID’s procurement reforms are defining the ‘how’ of localization

The U.S. development community has been advocating for locally led development under banners such as country ownership, the journey to self-reliance, and localization for more than 15 years. Yet, a significant shift occurred in 2019 when USAID released its first-ever Acquisition and Assistance (A&A) strategy . Before then, localization was more of a policy question: Would USAID actually commit to initiatives like Administrator Raj Shah’s 30% target or would that be undermined and minimized? After the A&A strategy was released, localization became more of an operational question: How would USAID do it? How would USAID change the way it does business, simplifying its requirements to award funding to acquire services and deliver assistance? How would USAID reform its procurement processes and compliance requirements so that local organizations in developing countries would see USAID as an attractive partner?

Then-USAID Administrator Mark Green wrote, “ The A&A Strategy is a shift away from traditional approaches that can unduly constrain our staff and partners … we will embrace USAID’s new approach to self-reliance … Diversifying our partner base and integrating locally-led development into how we deliver ….”

Since 2019 and the launch of the New Partnerships Initiative (NPI), less burdensome USAID procurement approaches like co-creation and concept papers have become widespread. Procurements restricted to local organizations occur regularly. USAID has begun to publish key documents in languages other than English. It has set up a website called Work with USAID.gov where local organizations can learn the basics of working with USAID and make themselves more visible to the development community.

USAID’s procurement team has also looked within the Federal Regulations to identify other opportunities for procurement reform. This year,  the White House Office of Management and Budget (OMB) took several steps in the right direction by issuing new Uniform Grants Guidance , affecting USAID and all federal agencies. One key change will allow federal grant recipients to charge up to 15% for their indirect cost recovery. That is a 50% increase over the previous ceiling, recognizing that local organizations have been absorbing the costs of doing business with USAID and that USAID should cover more of those expenses.

This issue is particularly important for expanding USAID’s partnership with local civil society organizations. Indirect cost recovery provides funding that organizations can use to strengthen their institutions, including compensating their leadership, developing proposals, training their staff, and keeping the lights on. Local organizations seeking to work with the U.S. Government for the first time do not have a Federal negotiated indirect cost rate agreement (NICRA) like established implementers and must absorb most of those costs themselves – an expense that can be prohibitive. OMB’s new Uniform Grants Guidance also embraces accepting proposals in languages other than English, lowering another barrier to entry and recognizing that local language skills are often vital for successfully implementing development and humanitarian programs.

In the same vein, a draft, the Locally Led Development and Humanitarian Response Act, would enshrine these procurement reforms and embrace several more by authorizing USAID to:

• Restrict bids to local entities on awards up to $25 million, five times the current ceiling.
• Accept the international accounting standards commonly used outside the U.S. so local entities expert in those practices can still apply.
• Allow USAID to begin working with organizations that have been unable to register in the System for Award Management (SAM), a United States government platform for paying vendors, due to its long waitlist.

At a recent Plan International policy event , USAID’s new Chief Acquisition and Assistance Officer Jami Rodgers outlined his goals for the team of six hundred procurement professionals he leads, as they make the binding day-to-day decisions about how USAID does business. He outlined the goals of the recently launched “A&A Accelerate” initiative. This includes a focus on recruiting and retaining contracting officers and agreement officers, including by investing in the USAID mission Foreign Service Nationals (FSNs), hiring eligible family members, and leadership certification. The recent 250% increase in the number of FSNs with administrative warrants certainly helps in this regard, and their ranks should continue to expand.

Rodgers also mentioned increasing interest in innovative procurement mechanisms like transition awards (an award to a local subrecipient to help it transition to becoming a direct recipient of USAID awards) and said he has encouraged his staff to continue to pilot, test, and scale novel approaches. He pledged to provide risk tolerance that would allow USAID to do business differently in service of the goals of locally led development. Transition Awards are a type of USAID award that delivers program results while also preparing local subrecipients to manage a USAID award in the future.

Yet much remains to be done. In April , the current USAID Administrator Samantha Power testified before Congress that, “It’s also just famously hard to work with USAID. We have a lot of compliance requirements, many of which are imposed by folks up here, but many of which we would embrace ourselves … . We’ve tried to simplify the application process, so it doesn’t crowd out those who don’t have the lawyers, the accountants, you know the armies of people to be able to comply.”

As the recent USAID and OMB procurement reforms become operational, a few more of those barriers will be coming down, making USAID’s shift to direct funding of local entities less burdensome and more impactful.

Networks as the new intermediary of a locally led and globally informed approach to development

The localization agenda has helped steer the global conversation on sustainable development in new and helpful directions–centering the critical role of local leadership and expertise and challenging old ways of working informed by colonial-era practices and mindsets. This said, current commitments from global donors to local organizations alone will not be enough to achieve the locally led development paradigm. Local actors still face barriers to accessing funding and recognition. For example, USAID support remains elusive and out of reach for a significant number of local organizations despite their meeting the criteria of local actors . To bring forth the needed investment in developing new mindsets among local and global actors alike, and also to support local actors to gain access to global insights and knowledge that will enable them to work in ways that are both locally rooted and globally informed. Intermediaries, such as networks, can play a valuable role in operationalizing localization agendas. 

Sustainable development happens when the people closest to the developing context drive and own the process. When the people in local communities are exposed to what’s working and what’s been learned in other similar contexts through a network of local actors, progress happens faster. This “locally led, globally informed” approach is ingrained in intermediary organizations such as Teach For All,  a global network of 62 independently led and locally governed civil society organizations- including Enseña por Paraguay – that is guided by a shared purpose, values, and vision, as well as unifying principles and standards that all network partners and our global organization are governed by.

The role of a global network is to accelerate the progress of its locally led partners. Yet this network structure has to date been under-appreciated by USAID and other bilateral and multilateral organizations as a potential intermediary to both accelerate locally led development and provide operational support. For example, through networks local organizations can access coaching and guidance to bid competitively for bilateral and multilateral partnerships. Enlisting the support of a global network intermediary could help USAID move the needle towards their 25% local funding target by accessing local partners with built-in support from global counterparts. Additionally, local partners within networks could have the benefit of accessing funding and partnerships they wouldn’t otherwise have the capacity to approach or implement alone. 

In some instances, local partners who participate voluntarily in order to advance their own local interests have faced penalties for being connected to a global network. This dynamic has raised the question of who defines localization. Even within the current discourse and despite well-intentioned efforts, it is too often Global North actors who set the localization priorities and approaches, while the voices of what local partners want and need are left unheard. Here again, networks are a way to enlist local partners and amplify their voices across contexts and towards a shared orientation of collective learning and impact towards our broader localization goals. 

Networks are an untapped resource that could help shape a new path forward and help bridge the gap from discourse and policy to implementation and action.

Pushing the needle on localization: How international actors can find a new role through centering local actors

The Network for Empowered Aid Response (NEAR) defines localization as a transformative process of changing the way support to communities is designed, funded, and delivered, where local response systems have the agency and resources they require to support communities before, during, and after crises. This approach not only strengthens the efficacy and sustainability of aid but also challenges existing power dynamics within the aid system by placing local response systems at the heart of community support. Local actors and communities must be at the forefront of driving, designing, and delivering aid, given their deep understanding of the complexities and needs within their communities.

International actors have a role to play, especially in response to increasing needs and more complex crises. To find their new role within the system, they must actively shift power to local organizations and be rooted in the values of solidarity, complementarity, trust, and equity. In practice, this would mean not only supporting but actively facilitating and centering the work of local actors and communities, strengthening their existing efforts without overshadowing their leadership.

There is concern, though, about the instrumentalization of the localization agenda by some international actors as the agenda gains greater political visibility within the global development sector. For example, there have been instances where INGOs nationalize their country offices or decentralize power from headquarters to country offices, conflating this with localization. Such actions can not only stall but even undermine the more ambitious objectives of localization—not to mention negatively impact the agency of communities and the role of local and national civil society. While the continuous growth of some international intermediaries is antithetical to localization, it is noteworthy that other INGOs are beginning to explore different business models. One example is ADD International , an INGO that is successfully shifting away from a traditional INGO structure with a UK-based head office and country offices, establishing a new global structure and exiting from existing programs within five years.

The challenges laid out above underscore the importance of establishing an agreed-upon definition of localization and of local actors, supported by local actors themselves. Definitions are indeed challenging; however, extensive work on the definition of local actor has already been done, paving a way for international actors to stand in solidarity and utilize a robust definition that has broad-based support among local civil society. For example, NEAR’s membership has defined non-state local organizations as those that are “present in locations before, during, and after a crisis; accountable to local laws; accountable to communities where they work; led by local nationals, and not internationally affiliated in terms of branding, governance, or financing (that results from that affiliation)”. The Inter-Agency Standing Committee also has a widely endorsed definition of local actors , utilized by a number of donors.

Another concern is that localization has stalled in humanitarian contexts. Both of USAID’s “Localization Progress Report” show that USAID funding to local actors for humanitarian assistance sits at approximately 1%, compared to the FY23 overall average of 9.6% of agency obligations. This figure is mirrored in the wider global humanitarian system, where only 1.2% of funding went to local actors in 2022. That same year, funding to international multilateral actors increased by 47% .

While international actors struggle to meet their localization targets, particularly in humanitarian contexts, local actors are creating ways to advance localization within even the most challenging environments. The Local Intermediary Actor Network (LIA) , for example, is committed to increasing funding accessed by smaller local and grassroots organizations. Another example is NEAR’s Change Fund , a global humanitarian response fund that is locally led, from its governance to its funding decisions. In some cases, philanthropic organizations—due to their higher degree of flexibility in funding—have played a key role in supporting new initiatives to get off the ground. USAID and other donors should leverage the collaboration and learning potential presented by the “ Donor Statement on Locally Led Development ,” which includes both government and philanthropic signatories.

Recommendations

Donors such as USAID play a vital role in creating policies and guidance that push international intermediaries to rethink their business models, act as equitable partners, and channel higher-quality funding to local actors. Donors can also require international actors, including U.N. agencies, to provide justification when not working with local actors, as well as exit strategies that were once common but increasingly a thing of the past. These changes, both incremental and cultural, push the needle toward local actors being in control of priority setting, design, and execution.

USAID should also:

• Incentivize and prioritize international intermediaries that are adopting new business models, shifting from models centered on their own continuous financial growth to models that are based on solidarity with local actors.
• Listen to local actors and measure progress on localization based on how local actors define progress themselves.
• Sustain and scale localization efforts in humanitarian contexts, where solidarity is needed most.

Support emerging and transformational locally led financing models to play a role in creating the system of solidarity of the future.

Global health and localization: While debating the need, we are missing the fact

Like the debate around renewable energy in the U.S., the debate around localization feels removed from reality.

In terms of energy, people joust about coal, renewables, and fracking, but the energy marketplace is already moving to its own rhythm toward pragmatic energy investments. For example, more than 80% of new electric generating capacity in the U.S. this year will be solar and battery storage investments. 

Similarly, few people contest any longer the reality around localization in the development sector, and localization themes already dictate decision-making by funders and INGO implementers. The INGO development landscape “operating system” is heavily weighted toward local ownership, solutions, and implementation.

Yet, the binary of the localization conversation persists, and it’s a risk. Are you local? International? Both? One, but trying to pretend to be the other? The goal should be a healthy ecosystem that advances development, the Sustainable Development Goals (SDGs), rights, progress, universal health coverage (UHC), and more. (Ruth Berg’s Friday Notes from December of 2023 captures the risk of the binary nicely.)

Instead of local versus international, it is the networked, transnational development model that appeals to an organization like mine, Population Services International (PSI). Like many INGOs, we see the value in local leadership and local context expertise, and we see the primacy of individual health consumer voices in the conceptualization and design of our interventions. National governments play a critical role in directing the flow of donor resources and coordinating civil society interventions—in our case of the health sector—to drive progress on health indicators and system resilience. Our role as an INGO is constantly evolving and adapting as local capacities strengthen and different actors become better positioned for implementation.

But just as local or national context specialists and implementers become more important, the need for transnational connection and learning grows even stronger. International implementers have decades of experience with large institutional funders and their compliance loads (e.g., USAID, the Global Fund); INGOs have developed purpose-built capabilities for resource mobilization from institutions and individuals that meet an obvious need in a sector where access to funding is getting more challenging, not less.

Funders looking for scalable solutions to transnational health and development challenges often insist on transnational implementing partners. This preference arises from a desire to try a similar approach in multiple settings, achieve economies of scale in implementation, and to capture wider learnings faster. 

PSI has observed a growing number of USAID awards that require INGOs to help to nurture and grow local implementers to eventually assume a “prime” role during the latter stages of an award. In some cases this has involved creating a local entity that can mature quickly or working with existing local entities to advance their institutional development. PSI has prioritized the institutional development of its own implementing infrastructure. This includes establishing structured governance processes at the country level, building networks for independent board directors who will become future governors of independent institutions, solidifying risk management and internal audit cultures within local entities, and partnering in these efforts once parts of PSI have been spun off to become independent.

In the last decades, we have spun off more than a dozen such entities, in our own institutional development journey. Examples include the Society for Family Health (Nigeria), Population Solutions for Health (Zimbabwe), and Family Health Solutions (Malawi).  These entities have established themselves as national civil society implementers providing value to their host governments, funders, and health consumers. Whether they choose to work with us on future opportunities is a matter of sovereign decision-making. But we value sustaining bonds of connection with these entities, as they share our strategic approach and engage in parallel problem-solving to PSI.

How can USAID and other funders continue to foster the development of this ecosystem of health implementers, including local, national, and international entities from both the Global North and the Global South? Much work has already been done in this regard. Key elements to ensure continued progress include:

• Transparency of dialogue and discussion with partners (to the extent permitted by procurement and acquisition restrictions) by USAID missions, regarding what is possible and by when as countries continue to take ownership of their development journeys. The fact that INGOs or local partners may be interested parties does not mean they don’t have valid points of view to share about the unintended effects of local or international procurement mandates. As U.S. Global AIDS Coordinator John Nkengasong often says, localization is not the objective; ending the HIV epidemic is the objective. Respectful dialogue about tactics versus strategies is often a missing part of the wider conversation with USAID.
• More resources for the Office of Acquisitions and Assistance (OAA) and more contracting and agreement officers overall across the agency are vital. Because more partners and more local partners mean more and smaller awards. The personnel needed to speed up this process are often lacking.
• The agency’s decision to increase the de minimus indirect cost recovery level from 10% to 15% of an award is very important and should unlock easier participation by local or national entities that do not have the track record to have justified a NICRA (negotiated indirect cost rate agreement). The lower level was too much of a disincentive to established local players whose cost structure and ability to deliver value were not meaningfully captured by a 10% cap. No one should fall for the fallacy that local implementation is or should be cheaper implementation, because it is not.

From Paris to progress: Moving the locally led agenda forward

George Ingram’s opening essay uses the 2005 “Paris Declaration on Aid Effectiveness” as its opening framing. We would argue that the Declaration, certainly a milestone when it was released almost twenty years ago, is no longer the most appropriate framework for assessing development effectiveness.

Since the “racial reckoning” that emerged in 2020, the international development sector has witnessed arguably the most profound challenge to its legitimacy in its history, with calls to decolonize donor and INGO practice and shift power to local organizations and leadership. Through this lens, the “Paris Declaration,” with its five equally weighted principles, looks outdated.

In global consultations Peace Direct has organized over the years, local actors around the world have articulated time and time again that local ownership is both the process and the destination. It is not simply a means to an end. This is the case even if it is less effective, at least in the short-to-medium term. This may seem counterintuitive to development professionals who wax lyrical about the virtues and importance of aid effectiveness, but let’s pause for a moment and consider the following:

• Are local organizations allowed to make mistakes as they navigate the complex contexts they operate in and gain experience in aspects of work that they have not had the opportunity to lead before? Mistakes are a rich source of learning, and yet local organizations are punished for making them because to do so makes them less effective implementers in the eyes of donors.
• Should local organizations in all areas be expected to compete equally as effectively with infinitely better-resourced INGOs despite decades of under-investment, prejudice, and patronizing behavior by donors and policymakers?

There has never been a level playing field, and there still isn’t one, so let’s not assume that local organizations can score goals each and every time the ball is passed to them. To be clear, local leadership does lead to better outcomes for communities, but one cannot assume that this will always happen quickly. This is why discussions around aid effectiveness should be reframed to consider issues of power, equity, dignity, and agency, which are aspects absent in most global frameworks. Inserting these dimensions reinforces why local ownership is so important in the debate around aid effectiveness.

If local ownership is both the journey and destination, it then becomes abundantly clear why definitions of local matter so much. Ask a local organization based in the Global South whether a country office of an INGO is genuinely local, and they’ll typically tell you no , in no uncertain terms. They will tell you the same for any of the other contortions that Global-North actors are performing to persuade themselves that there is a definition of local that applies to them. It is important for INGOs to accept the role of external actor.

What has been encouraging throughout Peace Direct’s consultations at the global, regional, national, and local levels over the past few years with local actors is that INGOs, donors, and other intermediary organizations do have important roles to play in rebuilding a new system of international cooperation. The quicker INGOs, bilateral donors, and other intermediary organizations can embrace their new roles and give space to local and community-based organizations, the more likely a reimagined system can begin to take shape.

So, what do these roles look like if they are not the traditional implementer, technical expert, funder, or grant manager? In early 2023, Peace Direct, an organization that has no country offices, employs no overseas staff, and does not implement projects directly, published a report outlining “ The Nine Roles that Intermediaries Can Play in International Cooperation . ”  The report highlights tangible, important roles for INGOs to play: interpreter, knowledge broker, trainer, convenor, connector, advocate, watchdog, critical friend and sidekick. Each one of these roles offers enormous potential to support locally led development in ways that are respectful and appropriate for this moment of transition, moving from an old paradigm into a new one.

It is important to note, however, that some of these roles should be temporary. They are designed to plug holes in a system that does not work as it should. In the effort to find relevance in a system in which Northern organizations have been dominant for so long, let’s not rush headfirst into a new set of roles that entrench positions of power and privilege. Ultimately, any new roles for intermediaries will not sustain the sector at the same size as it is now, and nor should they. The international role should diminish over time. That’s a measure of success in this new important reality.

In reimagining a new system, new structures, and operating dynamics should not come from the existing ways of doing. They must come from collaboration with the communities the locally led agenda seeks to center. A reimagined system of international cooperation should be mutually beneficial and uphold the value and dignity of local and community-based organizations in the Global South. It should address conscious and unconscious power dynamics, overcome the negative perceptions between local organizations and donors, and move away from extractive practices and toward more collaborative approaches. This is the message we heard loud and clear from a recent global consultation with activists and local actors from the Global South on how partnerships should look between the Global North and the Global South. The findings from that consultation can be found in the report “ Transforming partnerships in international cooperation .”

Most importantly, the four most commonly cited values that emerged from the consultation that should underpin the new system of international cooperation are trust, humility, respect, and mutuality/reciprocity. These might sound simple, but based on existing practice, they appear fiendishly difficult to embody. This is perhaps the most damning critique of the international development sector to date; that the values considered commonsense in how we treat our fellow human beings are not how Global South actors experience Global North professionals. We can and must do better.

Shifting INGOs to be the backbone of locally led development

As international development NGOs seek to adapt their expertise, experience, and leadership to support localization, they might find value in seeing themselves as a version of a “ backbone organization ,” a typology that has emerged from the collective impact movement in the U.S.

Collective impact is an approach that brings a diverse array of stakeholders together in collaborative partnerships focused on making social progress, often across a whole system, in a defined geographic place. A good backbone organization helps build and deepen the “civic infrastructure” that is key to successful collective impact, enabling expertise, relationships, resources, goal setting, data collection and analysis, and more. Backbones do not directly execute or manage programmatic interventions but instead enable the local changemakers who are doing the work by providing a variety of expertise, resources, and training.

Backbone organizations at the national level generally support a network of local place-based partners to succeed: Strive Together (where I serve on the board of directors), for example, serves a network of roughly 70 partnerships in communities across the U.S. The activities of a national backbone mirror many of the competencies and skills that INGOs have developed over time. While the analogy is not a perfect one, one could imagine an INGO developing a core strategy that is focused on serving and enabling a range of locally led organizations in the Global South, using lessons learned from the approach and mindset used by backbone entities in the U.S.

What are some of the key responsibilities of a backbone organization that could help define the core elements of a modern INGO in the age of localization?

Help local changemakers have a clear purpose and vision, and build the capacity and organizational strength to pull it off.

A backbone in the collective impact model offers tools and training designed to help its local place-based partners maximize their impact, taking advantage of proven methods to strengthen organizational development and ensure an effective purpose, strategy, and execution.

Strive Together, for example, has developed a theory of action that lays out the pillars of success for its partnerships mapped across a continuum of stages, so a local partner has the basis for building its strategy and can measure its own growth. Strive also facilitates peer exchange and relationships among all the partnerships in its network, providing the basis for shared learning, support, and leadership.

It has also created a training hub that offers a wide range of courses and trainings designed to help the staff and leadership of its local place-based partnerships grow in effectiveness and leadership. It also provides crucial and trusted support as organizations experience leadership transition, changes in resources, and other challenges.

Help set up and enable the effective collection and use of data.

Locally led partners often find it challenging to access, collect, manage, and make the most effective use of data. Backbones entities can leverage economies of scale to access investments in data infrastructure, collection, and analysis, bringing specialized expertise and offering training, experience, and infrastructure to their local partners. From technical data-sharing agreements, to physical infrastructure, to staff expertise to maximize the use of evidence and data in driving results, national backbones are the nexus for a wide range of services specific to the needs of the organizations in their networks.

Help build sustainable leaders, organizations, and interventions.

Backbone organizations help the partners and organizations in their network strengthen their long-term viability. In an era of localization, this might mean managing investments that require mechanisms at a scale that would be difficult for a local partner to do. It could also mean enabling a collective push for policy changes that the members of its network are prioritizing. A backbone is well-placed to help a network of local partners develop a shared policy agenda and collective strategy, and help that network sustain their efforts and facilitate the relationships necessary to make it a reality.

INGOs that follow best practices currently root their work in local expertise and knowledge, utilizing local people to run their projects. Many of them already perform various elements of what a national backbone organization does. Yet they are still often in the primary role of receiving the funds, developing the interventions, running the programs, and being accountable for the results. Adopting a backbone mindset means that INGOs would shift to see themselves as enablers of local organizations that would be the ones leading, owning, and doing that work.

Rather than create the program or system, ensure its effectiveness, and—once established—hand it off to local civil society or government, an INGO with a backbone mindset would see their role as bringing and building the capacity of local actors, who from the start would own and direct the programmatic interventions. Their currency and value proposition would lie in accompaniment, building the expertise and impact of local actors, facilitating a network that collectively engages on shared priorities and policy imperatives, and elevating that network’s shared purpose to new audiences. Many INGOs already do much of this: the change would be to take themselves fully out of the driver’s seat.

Not whether, but how international expertise can advance locally led development

There is a role for international expertise and intermediary organizations to facilitate global development. But that role has shifted since the pandemic, which shut down international travel and forced organizations to reimagine their operations. Moreover, the murder of George Floyd in May 2020 sparked a global reevaluation of organizational structures and systems to promote inclusivity and equity. As a result of these two dramatic societal shifts that intensified calls for the decolonization of development, international assistance organizations have been forced to not only make statements about more inclusive and equitable development but also walk the talk internally in their operations.

During my 26 years as a Foreign Service officer at USAID, including as counselor when I was designated to lead the localization efforts on behalf of the administrator under the Obama administration, I saw progress. But I am struck by today’s unparalleled focus on locally led development across the international assistance community. Under Administrator Raj Shah, a target of 30% was set for local organizations to receive direct USAID funding. Under Administrator Mark Green, the journey to self-reliance was the mantra with each USAID Mission developing country roadmaps in partnership with host countries. Under Samantha Power’s administration of USAID, locally led development builds on previous efforts and is augmented by the upheaval over the past four years that has accelerated a questioning of the role of international expertise and intermediary organizations. Although targets have been set for 25% of funding to be directed to local partners and 50% of programming to place local communities in the lead, the global development landscape has changed dramatically and requires an enhanced approach to how international organizations approach the use of international expertise. A target such as 50% is no longer acceptable. Rather, the goal of 100% for local engagement should be the new norm. This awakening not only affects bilateral and multilateral donors but also philanthropy and corporate donors.  

International development is at an inflection point, demanding more be done by global donors who control resources to improve global human development. As Administrator Power recently testified (at minutes 37:40-38:25), “We basically have programmatic dollars that have gone up 68% over recent years and operational expenses that have gone up 27%. So even with you (Congress) protecting our operational expenses, we’re still seeing a 3% cut in FY 24 … But that’s a big issue as we seek, again, to invest the staff time in working with local organizations and smaller organizations.” 3 The administrator went on to highlight the importance of growing USAID’s contracting officer workforce and empowering local staff, but there will never be enough USAID staff to partner with a larger percentage of local organizations, which is exactly the reason international intermediaries are needed.  

In 1991, following the Haitian coup d’état that deposed President Aristide, I, an inexperienced 25-year-old Presidential Management Fellow, was sent by USAID to run an office in Haiti. I quickly learned that the local Foreign Service National (FSN) staff and partners were the true knowledge centers, not Washington and surely not me. Over the years, I saw USAID make changes to ensure FSNs were at the table and local voices were consulted on everything from strategy to program implementation. I was heartened under the Obama Administration that this was elevated as a priority, which continued during both the Trump and Biden administrations. But given security access and unconscious bias, local staff and partners were and still continue to be prevented from being treated as equals in USAID.

There should be no debate about whether international expertise and organizations are needed, but there should be great debate about how they engage with local organizations.  The organization I led from 2019 to 2024, the International Youth Foundation (IYF), was founded with localization at its core, as demonstrated by its policy of not placing expats overseas unless required by the donor.

However, like other international development organizations, IYF had a large headquarters based in the U.S. with American executive and senior leadership teams responsible for the management and expertise delivered in countries across the globe in partnership with local actors. With the onset of the pandemic and global protests in 2020, IYF restructured its operations to reduce the size of its U.S. operations and shift roles to its local offices to directly deliver technical and operational support to local partners. This flipped the role of international expertise to one of supporting local teams as they directly strengthened local systems and built capacity, including financial, administrative, measurement, and evaluation, along with a host of technical areas led by local program teams. As a result, IYF’s executive and senior leadership teams evolved from being wholly American based in the Washington D.C. bubble to a diverse and inclusive team with representatives across the world. Moreover, the global team consisting primarily of Americans now plays a very different role than previously by supporting rather than leading local teams.

This is but one model of how an INGO can play an intermediary role in supporting locally led development. There are many more across the international development community. I would urge USAID to create an incentive for the sharing of case studies that can then inform USAID’s approach.

Many international organizations are on this journey of creating more equitable and inclusive models, which are critical to meeting the moment of a dramatically changed development landscape. International expertise will continue to be needed to play a supporting role to local organizations and actors. As much as USAID and other large bilateral donors and large philanthropies would like to increase direct engagement with local organizations, it requires staff. It is much easier for intermediary organizations that have a diverse funding pool to work in partnership with local actors, including government, private, and civil society, to co-design and implement initiatives. I hope people stop asking if there is a role for international expertise and start focusing on how it can be done for more inclusive and equitable development where local actors are in charge of their destiny.

As local as you can get

At the heart of locally led development and humanitarian action is the fundamental question: What, exactly , is local? Is it having local leadership, local boards, local registration, local affiliation, or all the above? These issues consume many of debates within CARE’s advocacy community.

Ironically, all these questions exclude the most local of all entities: community-based organizations (CBOs). These are the actors we should be centering. They are as local as you can get.

While there is no official data for assistance flows to sub-national organizations, it’s safe to say that very little aid reaches CBOs, which are, by definition, created and run by people from and in the community they serve. Many are not officially registered units, nor do they have organizational bank accounts or boards of directors, rendering them invisible to the locally led agenda. Most often, a visionary leader represents the entity, but that does not mean they are opaque, undemocratic, or unaccountable.

In every country to which I have traveled over three decades in the international development sector, there are virtually always local initiatives run by women at the village level. Some, like the Mata Masu Dubara networks of Niger , are highly organized networks with transparent governance systems. But most often, they are simply a motivated group of women who decided to take matters into their own hands and uplift their communities.

These micro-sized CBOs can have macro-sized impacts. One example of this type of group is the Village Savings and Loans Association (VSLA). These are far more than the typical savings group. VSLAs in over 77 countries have launched women into politics, taken on COVID-19 surveillance and education, reduced gender-based violence in households, and sent generations of children to school —all without an outside financial investment. Small impact? Multiply this by more than 800,000 VSLA groups worldwide.

It is rare that a CBO will be able to access anyone at USAID, let alone complete an application or meet compliance requirements. So, how to get funds to these highly impactful informal actors?

One answer is through a process called accompaniment in which intermediaries, which take many forms, walk alongside CBOs and provide advice when asked, capacity when invited, and small grants or fixed obligation awards exactly when and how the CBO needs them. Sometimes, this takes the form of buying a group a vehicle, paying for event space and catering, purchasing building supplies for the community, or paying for a trainer. It is really not that complicated. But it does require intermediaries to be in close contact over a long period of time with CBOs and their communities, much like foundation program officers track their grantees over time. Some international organizations have been doing this effectively for decades.

This approach delivers transparency and accountability to taxpayers and lawmakers. The intermediary organization is responsible for justifying and documenting each and every disbursement of funds or purchases, as every single partner to USAID does already.

A year after the Indian Ocean tsunami in 2004, I traveled to rural Sri Lanka and met an extraordinary group of women who named themselves the Tsunami Women’s Network. This group of women banded together and pooled what little they had to start helping other women in the community recover from the physical and emotional devastation.

As I wrote in my book, “Teach a Woman to Fish,” one of the women in the group shared with me:

 “All these charity groups came and then they withdrew. They did not have a long-term plan or program. Asha (name changed) suggested to us that a women’s savings society wasn’t the end of the journey, that we have to go further. At the initial stages she visited us several times, and she told us about how they organized themselves in [her village, location removed]. Asha pointed out the value of organizing and getting together. She also invited us to go to [her village]; that gave us an insight as to how we could organize ourselves. We started with the savings scheme, and now we have four divisions of savings groups. We got ourselves all together and formed the Tsunami Women’s Network. … It was a new era for us. Now we can go anywhere, talk to anybody, and ask any question we want. We are powerful now.” 4

Another of the members of the network scaled up this power for broader impact. Aruna’s (name changed) village had no water to drink. So instead of doing nothing, she organized a strong advocacy campaign. As she told the story : “I said to the local politician, ‘You provide the water, we’ll provide the labor.’ The village got the trenches ready, laid the pipes, and then told the guy, ‘Now turn on our water.’  The politician was so shocked, he went running and did it right then.” 5

Local groups of women acting together. This is where the magic is happening. Let’s get as local as we can and help these powerful community change agents get things done.

Cultivating a healthy global development ecosystem by harnessing the strategic power of organizational operations

George Ingram’s opening essay notes that the “2005 Paris Declaration on Aid Effectiveness” memorialized donor commitment to an effective, sustainable sector by adopting locally led approaches. Since then, donors have set increasingly specific targets for both the direct funding of local organizations and the integration of local leadership into the framing, design, implementation, evaluation, and accountability of development interventions.

As a Humentum report noted earlier this year, donor governments have deepened their fidelity to localization through the 2016 Grand Bargain localization commitments, the partnership principles of the 2030 Agenda for Sustainable Development , the Local SDG Platform , the Core Humanitarian Standard on Quality and Accountability , the Charter for Change , and the 2022 Donor Statement on Supporting Locally Led Development endorsed by 21 donor countries and subsequently by 26 private foundations. While divergent in their definitions of what constitutes local, these mechanisms reflect a general appreciation that donors and other stakeholders should be “recognising and enabling local actors’ agency in: framing; design; delivery, including control over resources; and accountability, in given local and operating contexts” where they work.

Given this nearly two-decade push for locally led approaches, some have expressed exasperation and disillusionment with the sheer dearth of funders, including USAID, who have yet to achieve these targets. They ask, “Why aren’t we there yet, and is it even possible?”

It is possible, and necessary. Increasingly, global development professionals view the sector as an interrelated and interdependent ecosystem. It is an ecosystem in which USAID and other donors, INGOs, and local organizations, including civil society organizations (CSOs) and national nongovernmental organizations (NNGOs), are highly interdependent for their institutional health and overall impact.

Humentum ’s recent report, “ Operationalizing Locally-Led Development: Cultivating a Healthy Global Development Ecosystem ,” stresses that the current health of this ecosystem, however, is undermined by power imbalances, collective mistrust, funding inefficiencies, and largely transactional partnerships. Indeed, for far too long, donors and international organizations have dictated too many programming elements. With few exceptions, donors have meted out highly restricted, compliance-laden funding that fails to fully cover CSOs’ costs of doing the work. As a result, CSOs and their leaders—those closest to the need—are frequently under-resourced, under-valued, and marginalized by the very sector that depends on their success. All of this, in turn, has reinforced deeply entrenched power imbalances.

There is a growing recognition that for the whole to be healthy, each institutional actor needs adequate resources, organizational autonomy, operational capacity, and relational power to thrive. Adopting a systems-change approach, seen through the lenses of locally led and equity, can channel common values to build and buttress the systems and structure of collective work, determine who does the work and how to work together, identify how that work is funded, and agree to shared accountability structures for how the work is being done.

Since 2021, Humentum’s engagement with around 5,000 professionals from over 100 countries to identify and interrogate the hydraulics of sector transformation uncovered within four key components of organizational operating models strategic steps to cultivate a healthy ecosystem. These include:

• Institutional architecture : Make change happen through more decentralized, democratized governance and organizational structures , bringing decision-making and resources closer to those who do the work.
• People and culture : Implement equitable and values-based human resources and compensation policies and practices , taking a principles-based approach to managing people, organizations, and partnerships.
• Funding and financial systems : Fully fund organizational operating and overhead costs, ending the non-profit starvation cycle , invest in institutional capacity, and create mechanisms for more locally defined, flexible, trust-based funding.
• Risk and compliance : Design and implement protocols for risk-sharing (rather than risk transfer), mutual accountability, and simplified and harmonized due diligence and compliance requirements.

For a healthy global development sector, the focus must be on “how” locally led and equitable development is operationalized. Truly transformative change to the ecosystem will most readily happen when the sector harnesses the levers of change within individual and collective operational policies, practices, and principles. This can be simultaneously simple and complex because the “how” looks different depending on where you sit in the ecosystem:

• Donors: Donors have a special opportunity and obligation to nurture and sustain the global development ecosystem. Because they control the purse strings, donors’ power can subordinate and stifle the role of international and local actors alike. To enable the sector’s transformation, donors must fund the transformation process. (Re)balancing power requires the financial resources, systems-change tools, and accountability mechanisms necessary to incentivize transformation. Donors should invest their resources in the operational vitality of organizations and then get out of their way. Let them do what they do best without imposing arcane and burdensome compliance requirements: Provide flexible, multiyear funding, full cost recovery (cover overhead expenses), and unrestricted funding. Donors should challenge themselves to implement simplified, flexible procurement processes that facilitate local actor design and leadership. Finally, all donors with locally led targets, such as USAID, should set and mandate reporting on indicators that track progress to local ownership as both a process and an outcome. USAID could increase accessibility to its funding by simplifying procurement mechanisms and compliance requirements that are within its control. For instance, USAID could uniformly apply its policies and practices to U.S.-based and non-U.S. entities alike, mandate reporting on its localization indicator, and include in its funding agreements clear expectations, when and where applicable, for CSO leadership and INGO capacity-building, networking, advocacy, and similar roles.
• International (for-profit and non-profit) organizations: INGOs can make a change when they interrogate their operating structures, hiring, retention, and compensation policies, examine their due diligence requirements of CSO partners, and ensure they are playing a value-add role in the sector by bringing globally-tested approaches, experience, tools, and advocacy for locally led development. INGOs can infuse the values underpinning locally led, equitable development in how they convene, partner, capacity build, and implement programs. By being introspective and transforming their operations, INGOs exercise their power to enable a healthy ecosystem. This work is well underway – with many INGOs in the “messy middle” of the transformation journey.
• Local or national civil Society organizations : CSOs can live their values by reflecting them in their operating policies and practices. They can invest time and resources in peer-to-peer learning opportunities, operational development, and storytelling for greater impact. CSOs are increasingly harnessing the power of the collective through regional and global networks to influence donor policy change, demanding greater deference to their deep experience and expertise.

Save the Children’s recommendations for advancing local engagement through programming and procurement

Localized approaches that shift power, influence, and resources to those affected by development challenges and humanitarian crises produce better and more sustainable results. Save the Children’s localization policy supports this understanding by acting as an ally to local actors, including communities and children themselves, in elevating their voice and leadership to drive locally meaningful change. Historically , Save the Children has emphasized the agency and leadership of children and local actors to drive this change through various initiatives, including child rights governance and community-led development. In response to growing development and humanitarian challenges the world over, and an intensified sector-wide push to advance locally led solutions, Save the Children is reevaluating its engagement with local stakeholders and communities. A long-term transformation is taking place to better fulfill this ambition.

USAID’s efforts to advance locally led development and humanitarian assistance in its programming and procurement represent a significant advancement. While progress is ongoing, concerted efforts have resulted in increased and higher-quality funding going directly to local and national actors. Additionally, the introduction of 14 Locally Led Programs indicators will guide more equitable and meaningful engagement of local actors across USAID’s portfolio. USAID’s efforts to engage with peer donors to influence their adoption of this agenda showcase a significant advancement beyond its own programs. These efforts, and more, have the potential to contribute to a fundamental shift in how the development and humanitarian sector operates, fostering a more complementary ecosystem of actors working together at the international, regional, national, and local levels to effectively respond to the greatest challenges of our times.

Much remains to be done. Globally, local and national actors still struggle to access direct funding despite various pledges and commitments, and in some contexts are being pushed out of their own markets by local affiliates of international organizations they struggle to compete against. Moreover, despite sector-wide efforts to foster more meaningful and equitable partnerships between local, national, and international actors, many of the local actors Save the Children interacts with in many countries report not feeling the results of this transformation at scale. In many contexts, Save the Children staff observe the push for localization resulting in the consolidation of considerable resources and power in the hands of a limited group of large, well-established national entities, limiting the engagement of a diverse range of local stakeholders and diminishing their ability to meaningfully lead change in the communities they represent.

In order to better ensure the meaningful participation of local actors and to foster a more complementary ecosystem of actors at all levels, donors like USAID can and should leverage programming and procurement practices to incentivize this change at scale. USAID could consider the following actions: 

• The Locally Led Programs indicators are intended to create agency-wide incentives to use partner-led approaches like program co-design and demand-driven capacity strengthening. To maximize the transformational impact of these indicators, USAID should extend these reporting expectations to INGO partners for their engagement with local and national actors. 
• USAID is now translating bids into multiple languages and allowing non-English submissions. Simplifying proposal instruments, specifically notices of funding opportunities and requests for proposals, and increasing the use of concept notes and oral submissions must make headway. The current instruments are dense, burdensome, and difficult to navigate for local groups, especially from non-English speaking countries.
•  International actors clearly have important roles to play in localized development and humanitarian sectors. However, many will not grow into these roles without the right incentives. To foster these shifts in roles, USAID could make greater use of existing and new procurement mechanisms that delineate specific roles for international, local, and national partners such as the New Partnerships Initiative , Transition Awards , eligibility restricted solicitations (e.g., “locals only”), and more.  
• When considering how to foster more meaningful and consistent engagement of local actors in USAID processes, it becomes critical to define whose engagement is being sought out. As indicated in Publish What You Fund’s “ Metrics Matter II ” report, roughly half of the funding reported under USAID’s 25% direct local funding target is going to truly indigenous entities originating from the communities they serve. To ensure that a diverse range of truly local voices are engaged in USAID programming and procurement, USAID could apply the IASC (Inter-agency Standing Committee) definition of local and national non-state actor in reporting against its 25% direct funding target, in line with its status as a signatory to the Grand Bargain .  
• Fostering meaningful engagement with local actors takes time and visibility. Tools like the USAID Business Forecast offer invaluable insights into USAID’s programming priorities in advance. However, in the absence of a Request for Information, draft Request for Applications , and other forms of prior notice, development partners often lack insight into the detailed programmatic priorities of USAID Missions. Without these insights, organizations may struggle to identify the right partners to engage meaningfully in the early stages of program design. USAID could provide more details on their programmatic priorities in the USAID Business Forecast to better support the early engagement of local partners in true co-design.

USAID has made important progress on commitments to be more locally led and to shift more and better-quality funding to local actors. To enhance locally led development and humanitarian solutions, consistent and scalable implementation of these commitments will be essential.

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The authors extend special appreciation to John W. McArthur for serving as editor and to Patrick Fine and Tony Pipa for serving as reviewers of this series of viewpoints. The views expressed here are the authors’ own and do not necessarily reflect those of the Brookings Institution.

• For example, the 2011 Busan Partnership identified four guiding principles: ownership of development priorities by developing countries, focus on results, inclusive development partnerships, and transparency and accountability to each other.
• This third question was modified during the roundtable discussion as reflected here.
• Samantha Power, Hearing on “A Review of the President’s Fiscal Year 2025 Budget Request for the Agency for International Development”, April 9, 2024, Senate Committee on Appropriations, at 37:40-38:25.
• From Ritu Sharma, “Teach a Woman to Fish: Overcoming Poverty Around the Globe . ”   Page 44.
• From Ritu Sharma, “Teach a Woman to Fish: Overcoming Poverty Around the Globe .” Page 44.

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