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Tsasis C. Rethinking institutionalized learning in the context of pandemics. HPHR. 2024. 87. https://doi.org/10.54111/0001/IIII1
Pandemics have posed a long-standing challenge to global governance mechanisms, with COVID-19 a most recent example. Using the perspective of organizational learning theory, this paper examines factors that may hinder the effectiveness of institutionalized learning as it relates to pandemic preparedness and response. It does so through a focus on national sovereignty, an absence of shared values, and poorly defined actor roles and responsibilities. Taking a unique approach by reconceptualizing institutionalized learning, this paper concludes that although beneficial outcomes are predicted if institutionalized learning takes place, we must develop mechanisms that facilitate the enactment of this learning at a global level. This will have the benefit of enhancing pandemic readiness and endorsing decisions that allow for resources to be effectively, equitably, and efficiently mobilized.
Global governance mechanisms, defined herein as the policies, organizations, and institutions that work to resolve and mediate difficulties faced at the global level, have struggled to adequately respond to the challenges of pandemics. Infectious diseases are a significant public health issue. They begin insidiously, while transmission increases exponentially, often spreading beyond local borders before a visible threat and its point of origin can be identified.1 A convergence of factors, such as globalization (which has encouraged migration, travel, and trade), increasing urbanization and population growth, changing environmental conditions, demographic shifts towards aging populations possessing weaker immune systems, and clearing natural habitats for agricultural use resulting in greater interaction between humans and animals, have set the stage for the rapid transmission and distribution of disease.1 Global governance currently lacks effective coordination with respect to pandemic response due to a multiplicity of factors, including a lack of enforcement mechanisms, deficient definitions of actor roles and responsibilities which lead to poor accountability and promote competition, national sovereignty concerns, and ultimately, poor collaboration resulting in barriers to a collective response.2,3 Using organizational learning theory, which considers how organizations respond to change and adapt, the effectiveness of the COVID-19 pandemic response in prompting the integration of learning into practice (institutionalized learning) on a global level will be examined herein. Although many factors contribute to the issue, this paper will place the focus on national sovereignty, a lack of shared values, and poorly defined roles and responsibilities, in highlighting how the benefits of institutionalized learning have not been fully realized.
Organizational learning theory examines the ways in which organizations adapt their behaviour based on the acquisition and utilization of knowledge to remain relevant and improve performance.4,5 Sharma et al. (2021) suggest that governance structure, institutionalized learning (which is defined as the ability to integrate knowledge into policy or performance guidelines), and healthcare infrastructure investments, all impact the ability of countries to respond to rare events, such as pandemics. They further highlight that institutionalized learning (which is critical to adaptive responses as it is a way in which organizational learning can occur) depends on the degree that countries have been affected by past rare events. This is because the severity of their experience motivates the consolidation and integration of knowledge in actionable ways. The concepts of ‘transformative learning’ and ‘re-interpretive learning’ are connected to institutionalized learning as they are two types of learning that affect organizational behaviour to different extents by linking actions/practices to performance outcomes, motivating organizations to act differently. 6
Within the last twenty years, six public health emergencies of international concern (PHEIC) have been declared based on viral diseases which have brought forth opportunities for institutionalized learning.7 Historically, past mechanisms and actions to prevent the spread of disease have been predominately dependant on national surveillance mechanisms and countries voluntarily declaring their circumstances to the World Health Organization (WHO).7 Over time, in response to rare events, institutionalized learning can be seen to have taken place through the creation of pandemic response instruments, such as the International Health Regulations, the Global Outbreak Alert and Response Network, the Pandemic Influenza Preparedness Framework, and the Public Health Emergency Operations Center Network.8
Perhaps most well-known are the International Health Regulations (IHR), a form of binding international law designed to rapidly detect, contain, and manage disease outbreaks among all WHO member states.9 After their creation, the IHR have undergone a series of adaptations based on further institutionalized learning to improve procedural guidelines and mechanisms of action grounded on learnings gained from an increasing range of public health risks experienced.10 Most notably, revisions made in the 2005 regulations included a broader scope of events/circumstances that qualified for early detection, a new threat classification known as ‘public health emergencies of international concern,’ and the establishment of National Focal Points to improve country communication with the WHO.10
While multiple challenges such as geopolitical conflicts, digital inequities, and misinformation exist, country awareness and standardized compliance are necessary for regulations to produce intended benifits.9,11,12 However, the Review Committee on the Functioning of the International Health Regulations during the COVID-19 Response concluded that the IHR were not optimally implemented during the pandemic due to lack of adequate enactment at the international (WHO) and national (individual country) level.9 Their report determined that while the IHR are an important mechanism, there exists an “inherent tension” between their aim of safeguarding health and public demand to support local economies.13 These conflicting aims have constrained the WHO’s ability to recommend travel ban advisories under the IHR as they run the risk of adversely affecting trade and frustrating countries if unnecessarily implemented, as was seen in Canada’s response to the restrictions placed on the country during the SARS epidemic.13,14 Furthermore, the public mindset no longer supports lockdowns that constrain economies due to the negative impacts this has had on society and the social determinants of health. Such impacts have included increased poverty and homelessness, loss of livelihoods and income, and disruption to food supply chains which has contributed to undernutrition.15 Thus, the aversion to sharing information for fear of travel bans was identified as a main reason for limited country compliance to the IHR, despite knowledge-sharing being acknowledged as an important tool in pandemic management.13 The poor implementation of the IHR highlight how the enactment of institutionalized learning may be hindered by national sovereignty at times due to countries’ inherent desire to make decisions supporting their best interests, despite not necessarily aligning with global benefit. This may be alleviated through ensuring open channels of communication exist between impacted countries and the WHO that frame information-sharing as a positive initiative. This could be accomplished by WHO-assistance in facilitating safe trade through the use of mitigation strategies that minimize risk while continuing to support economies. In addition, non-state actors such as non-governmental organizations can be encouraged to share information with the WHO to further contextualize the landscape.
Inadequacies centering around risk management and incomplete information in informing complex decision-making have also contributed to ineffective pandemic response. With regards to pandemic prevention and management, the WHO acts in a technical and coordinating capacity to help strengthen national health surveillance, provide best practice guidelines, and motivate a collective response.16 Despite the WHO’s positive intentions, issues have been highlighted in implementation, influencing its effectiveness and impacting its ability to fully benefit from institutionalized learning and the experiences of past pandemic management.8 Kuznetsova (2020) brings some of these issues to the forefront, including inaccurate risk assessments/estimates of disease threats, which have resulted in the WHO engaging in either a “heightened or limited response”.8 Since the effectiveness of retrospective organizational learning may be hindered by changing conditions, it may benefit from also engaging in risk management approaches to allow for an optimal pandemic and health system response.17 However, applying risk management to the prediction of pandemics poses its own challenges due to the interconnected impacts pandemics create as disease spread interacts with systems, policies, and people.
Composed of 194 member states, the WHO derives health information from the Global Focal Point Network, a series of national centers designed to report incidents to the WHO.18 It should be noted that territories/regions not considered UN member states are excluded from the WHO and do not contribute to this network.19 Compounded by a lack of willingness from member states to share information that may shine a negative light upon them, collective action is compromised, heightening the uncertainty of risk assessments that influence global strategy.20 To address this, a better approach may be one in which countries buy into the knowledge-sharing process based on their adherence to shared values and shared understanding regarding a collaborative and collective response, as this has proven effective in enhancing the cohesion of networks.21 For this to occur, a focus on diplomacy is critical to mitigate clashes caused by different perspectives, plans, and political interests, so they do not become obstacles in the collaborative process.22 McKinley et al. (2021) highlight the low priority preventative pandemic measures receive despite pandemics being perceived as an issue of great severity. This showcases the need for shared values among decision makers and a global consensus to be developed to frame upstream preventative measures as an issue of shared importance.17 When addressing global issues, despite the existing gradient of risk based on differing infrastructure and preparedness plans, location, population demographics, and unique contexts based on the social determinants of health, we must have a collective response that is based on common goals and shared values if effective global action is to take place.
The COVID-19 pandemic has showcased that national action alone is no longer effective in curbing the spread of disease, calling for a clear understanding of the complimentary role each nation will play in future pandemic preparedness. The current drafting of an international pandemic agreement to act as a legally binding instrument outlining provisions for pandemic prevention and response, indicates that progress is being made on a foundation of shared goals and values to address issues such as vaccine equity and the production, distribution, and access of personal protective equipment. Encompassing values such as respect for human rights, inclusivity, accountability, transparency, and solidarity, the proposal for the “WHO Pandemic Preparedness Treaty” describes a common interest in a “safer, fairer, more equitable and better prepared world to prevent, respond to and recover from pandemics”.23 Proponents support the creation of the treaty, seeing it as an opportunity to revise current approaches based on the information gained from pandemic response efforts, highlighting the treaty as an example of transformative learning as it fundamentally challenges core assumptions, leading to extensive revision.6,20 However, critics have explained that it is imperative that this treaty clearly define the roles and responsibilities of countries, as well as boundaries on the interpretation of these responsibilities if equity and human rights are to be secured.24 Quantifiable metrics must also be incorporated for processes to be assessed on a regular and continuous basis if long-term accountability and transparency is to be promoted. Transformative learning can be further supported through education to embed new learnings into mainstream thinking and set the conditions for progressive advancement and future preparedness.
Even though proponents argue that improvements have been made in the sector of pandemic preparedness and management through the incorporation of lessons learned from past experiences, the incremental amount of progress made is not sufficient to allow for quick adaptation in this high-risk infectious disease environment. Countries can no longer structure preparedness plans in isolation due to the environment of rapid change, uncertainty, and interdependence we live in. Furthermore, gathering the outputs of institutionalized learning from individual countries alone is not sufficient either without identifying and evaluating the influence of current conditions that may dictate certain courses of action.22 This is because knowledge gained from the national level does not necessarily make visible the power imbalances, resource distribution, political influence, and interdependencies that can clearly be seen at the global level. As such, the ability to keep track of current events and influences is an important component of readiness if we are to cohesively respond to pandemics with an effective global strategy.22 Using the metaphor of a puzzle, connectivity is important because it influences the picture that emerges. Although each piece of a puzzle is important to the formation of a full picture, that picture cannot be seen by looking at a single piece alone, or even many pieces randomly gathered together. It is only when the pieces fit together, much like knowledge situated within its context, that a relevant and useful pattern can emerge, allowing for informed decisions to be made and resources to be effectively, equitably, and efficiently mobilized.
In conclusion, institutionalized learning is an important component to addressing the issue of pandemic management that must be supported by strong global governance to collect information, coordinate responses, and act as a repository of knowledge. As predicted by organizational learning theory, institutionalized learning has occurred from our experience with the COVID-19 pandemic, with transformative learning becoming visible in the form of a WHO Pandemic Preparedness Treaty. However, if the full benefits of institutionalized learning are to be realized, issues surrounding national sovereignty and country roles/responsibilities must be addressed. Shared values must also be cultivated and supported through diplomacy to strengthen healthcare systems and improve pandemic response. Pandemics recognize no borders and although organizational learning theory predicts beneficial outcomes if institutionalized learning can take place, we must develop mechanisms to enact institutionalized learning at the global level to improve pandemic preparedness. Currently, inadequate global governance and poor information-sharing hinder development in this direction and must first be addressed in moving forward. In essence, if we wish to gain a full understanding of the complex picture infectious diseases present, we must leverage the possibility of global institutionalized learning to better understand and account for connectivity when planning effective responses.
Catherine Tsasis is an Ontario scholar and is presently pursuing her university studies in Global Health. She has an interest in public health and health equity.
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