Ali Akbari-Sari1, Elham Ahmadnezhad2, Zhaleh Abdi3, Sahand Riazi-Isfahani2, Sara Saffarpour2
1Department of Health Economics, School of Public Health and National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 2Health Observatory Secretariate, National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence: E. Ahmadnezhad). 3Department of Research and Education, National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran.
Abstract
Background: The COVID-19 pandemic increased the need for high-quality, timely evidence to support urgent policy decision-making.
Aims: To describe the experience of evidence-informed policy-making during the COVID-19 pandemic in the National Institute of Health Research in the Islamic Republic of Iran.
Methods: Institutionalization of the COVID-19 rapid response system comprised the following steps: organizing a committee, informing the policy-makers, drafting a timeline, and developing query and response forms.
Results: The COVID-19 rapid response system addressed the questions of 40 policy-makers through synthesizing and analysing evidence, as well as developing knowledge products. The main challenge was lack of data and research evidence.
Conclusion: A national body needs to take responsibility for the establishment and management of the COVID-19 rapid response system in order to provide valid evidence to policy-makers. Over time, it should be strengthened to respond to epidemic conditions, and periodic evaluations of its institutionalization should be conducted.
Keywords: COVID-19, evidence-informed policy-making, Islamic Republic of Iran, rapid response system, universal health coverage
Citation: Akbari-Sari A, Ahmadnezhad E, Abdi Z, Riazi-Isfahani S, Saffarpour S. Institutionalization of the COVID-19 rapid response system for health system policy-makers in the Islamic Republic of Iran. East Mediterr Health J. 2023;29(6):xxx-xxx http://doi.org/10.26719/emhj.20.xxx Received: 01/08/22, Accepted: 08/12/22
Copyright: © Authors; licensee World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
Introduction
There is a growing global interest in achieving universal health coverage by strengthening health systems following the introduction of the United Nations Sustainable Development Goals (1). Decisions to achieve these goals need to be informed by evidence. Evidence-informed policy-making is a complex process, and the time required to generate evidence usually exceeds the time that policy-makers are willing to wait (2–4). The COVID-19 pandemic forced decision-makers to make rapid decisions under time pressure and situations of scientific uncertainty, which highlighted the need for adaptation of evidence-informed policy-making to changing circumstances. Some solutions have been proposed, and 1 of the most important is the establishment of a rapid response system (5). According to the Evidence-informed Policy Network, rapid synthesis of the best available research evidence on pressing health issues can provide policy-makers with a sound basis on which to inform their decisions, and this highlights the importance of establishing a mechanism for generating and disseminating evidence in a timely manner (6, 7). An additional example of this can be seen in Canada, where a rapid response programme was developed to serve as a key mechanism for facilitating user-pull (8). Evidence-informed policy-making is now inevitable, and each country must implement its own plan and adapt it to situations that require a rapid response system.
Immediately after detecting the first case of COVID-19 in the Islamic Republic of Iran, the authorities moved quickly to respond by deploying a whole-of-government and whole-of-society approach (9). Hence, all sectors committed to respond to the pandemic. Numerous national committees were formed and policies were formulated and implemented (10). In this regard, the National Institute of Health Research (NIHR) tried to fulfil its mission by taking an active role in tackling COVID-19. NIHR as a national body has 2 main functions of health observation and rapid response. To realize the latter, NIHR addresses the knowledge gap in situations where health system decision-makers need support through access to and synthesis of optimally packaged, relevant, and high-quality research evidence. The aim of this study was to describe the process and establishment of the rapid response system as evidence-informed policy-making during the COVID-19 pandemic in the Islamic Republic of Iran.
Institutionalization of the COVID-19 rapid response system in the NIHR
Interventions
The specific intervention was the establishment of a national rapid response system against the COVID-19 pandemic in the Islamic Republic of Iran, to provide relevant research evidence that addressed urgent questions raised by policy-makers. Senior policy-makers at the Ministry of Health and Medical Education were identified as the primary stakeholders, and the key players were COVID-19 experts, researchers, and academics.
Process of the activities
The NIHR has a rapid response system, and the new intervention was an adaptation of the current structure to the COVID-19 pandemic situation. The NIHR organized a committee for evidence-informed policy-making, with the following subcommittees. (1) The Steering Committee determined the work plan, priorities, and general scope of activity; estimated the budget; reviewed the proceedings; oversaw, planned, and organized meetings; coordinated and communicated updates with policy-makers; informed the technical committee; and made decisions about allocation of resources. (2) The Advisory Committee had an arbitration role, providing expert advice and guidance on matters within their field of expertise. The committee’s critical role was to review and approve materials for publication. Their expertise enabled them to provide valuable feedback on content, accuracy, and relevance. They carefully scrutinized products to ensure that they meet quality and rigor standards. After the review, they granted permission for publication, indicating rigorous evaluation and high standards. This ensured that published materials were reliable resources for policy-makers. (3) The Technical Committee was in charge of developing all products.
The managers and senior policy-makers of the Ministry of Health and Medical Education were informed of the COVID-19 rapid response system. The rapid response system established specific timelines for different stages of the process, with the initial stage taking 3 business days, the subsequent stage 7 business days, and the final stage 30 business days. These timelines allowed for identification and summary of relevant systematic reviews, which were delivered in a timely and efficient manner to decision-makers.
To facilitate the process of receiving and responding to queries from policy-makers and senior health managers, a specific form was developed. This query form included various elements, such as the names of the policy-makers submitting the query; a well-defined question formulated as a query; information on the intended use of the response (e.g. for macro or micro-level policy-making, mass media, etc.); and the timeframe within which the response to the query was required. These elements helped streamline the process of receiving and responding to queries in a timely and effective manner. The response form utilized in the rapid response system was comprehensive and included a range of information such as the name and affiliation of the applicant, as well as the question that had been answered and the deadline for the response. The form also included key findings, review methods, results, and conclusions. It had a section for references, allowing for transparency and accountability in the sourcing of information.
Process of evidence preparation
The NIHR COVID-19 rapid response system included: finding the best and most relevant evidence; synthesis of the evidence and production of rapid reviews; and generation of meta-analyses in response to user-defined queries.
The evidence was synthesized using the following steps: (1) searching databases such as the Cochrane Library and PubMed; (2) determining the appropriate inclusion and exclusion criteria for extracting evidence; (3) extracting data from final studies; and (4) analysing the data. Different types of evidence were used, especially systematic reviews, meta-analyses of randomized controlled trials, and evidence-based clinical practice guidelines based on systematic reviews of at least 3 randomized controlled trials, which were the first choice. All products were indexed on the NIHR website and delivered to policy-makers by official correspondence. They were also presented to policy-makers in a series of meetings.
Main outcomes of COVID-19 rapid response system
The committee answered > 40 important questions up to the time of writing this paper. The following topics were covered.(1) Rules for holding mass gatherings, including religious meetings and sports (the evidence led to closure of mosques). (2) School reopening (the evidence led to a halt in reopening). (3) Rate of reinfection and antibody persistence, which led to the formation of a serosurveillance system in the Islamic Republic of Iran. It was hypothesized that herd immunity might lead to disease control and that no vaccine would be needed. This led to the refusal of some individuals and even policy-makers to take the vaccine. The seroepidemiological studies conducted through the serosurveillance system showed that reinfection was possible and antibodies were not persistent. This prompted policy-makers to put vaccination on the agenda (11). (4) Administration of the first vaccination booster for specific groups (evidence showed that booster doses were effective). (5) The effectiveness of oral and injected antiviral drugs. A rapid review of chloroquine, favipravir, remdesivir, monolopiravir, and some other drugs was carried out. Remdesivir has been widely used in the Islamic Republic of Iran, and the Annual Pharma Statistics Report of the Iranian Federal Drug Administration (2020) mentioned remdesivir as the most widely used drug. Evidence showed that remdesivir was not effective.
As an additional outcome, by creating a COVID-19 information platform and the associated website, the evidence was available for public use and was widely disseminated. This information was also used by the media and some of the questions made headlines in the official media (NIHR; https://nih.tums.ac.ir/En).
Key challenges and related strategies
The important challenges are as follows. (1) Limited human resources posed a challenge to providing prompt responses to queries because of the unavailability of sufficient personnel. This challenge was compounded by difficulties in managing time constraints. In order to overcome these challenges, teams were formed to provide answers to queries instead of relying on individual efforts. This team-based approach expedited the response process, enabling more timely and efficient delivery of responses to policy-makers and senior health managers. (2) Lack of technical expertise. Given the variety of the questions, it was a challenge to ensure the required technical expertise within teams. The challenge has remained, and the committee has worked to expand the range of expertise. (3) Finding appropriate evidence to address knowledge gaps due to the novelty of COVID-19. To address this issue, relevant sources were regularly monitored and primary data were generated. (4) The current mode of knowledge-sharing in the NIHR is based on a pull platform, which involves policy-makers and senior health managers sending their queries to the committee. However, it has been recognized that this approach has limitations and there is a need for a more collaborative exchange platform.
To address this challenge, a national framework was developed for consideration by the Ministry of Health and Medical Education. The framework aims to facilitate the exchange of knowledge and expertise between stakeholders through the establishment of a collaborative platform. The proposed exchange platform will enable stakeholders to share information and best practices, engage in discussions and debates, and collaborate on research projects. By moving from a pull to an exchange platform, the NIHR aims to create a more collaborative and inclusive environment for knowledge sharing, which will facilitate the implementation of evidence-based policies and practices. This shift will also help to overcome the limitations of limited resources and expertise, by enabling stakeholders to work together towards a common goal. Overall, the proposed exchange platform has the potential to enhance the quality and relevance of research and policy-making in the field of health.
Key lessons learned
The most important lessons learned were as follows. (1) A national body should take responsibility for management of the COVID-19 rapid response system in order to provide timely evidence. Consideration should be given to strengthening the capacity of its potential members for various situations. (2) Development of a structured format for receiving questions will facilitate the process by streamlining the flow of information. A format tailored to the needs of knowledge users will prevent dispersion of queries and ensure a clear and concise understanding of the information sought. (3) To consider the dissemination of responses in the form of policy briefs or factsheets. The use of mass media will make the rapid response more visible. (4) Policy dialogue is recommended to foster mutual understanding between policy-makers and respondents and to close any knowledge gaps. This will involve exchanging information, perspectives, and experiences among stakeholders to promote a more informed approach to policy-making. It will also enable stakeholders to collaborate, identify common goals and challenges, and develop potential solutions and strategies. (5) Establishment of the COVID-19 rapid response system could be promoted at subnational levels to enhance the culture of evidence-informed policy-making.
Conclusion
We aimed to explain the process involved in the institutionalization of a national COVID-19 rapid response system in the Islamic republic of Iran. The timely response to the questions of policy-makers was challenged by the rapid spread of COVID-19. The establishment of a national system that is supported by senior health policy-makers seems indispensable. It is imperative to develop the capacity to generate and synthesize reliable evidence in a timely manner to ensure its effective utilization. In order to maintain the effectiveness of the COVID-19 rapid response system, periodic evaluations should be conducted to assess its structural and functional capabilities and make necessary modifications.
Conflict of interest: None declared.
Acknowledgements
The authors would like to acknowledge the contribution of all committee members.
References
1. Kieny M, Bekedam H, Dovlo D, Fitzgerald J, Habicht J, Harrison G, et al. Strengthening health systems for universal health coverage and sustainable development. Bull World Health Organ. 2017 Jul 1;95(7):537–9. https://doi.org/10.2471/BLT.16.187476 PMID:28670019
2. Head BW. Toward more “evidence-informed” policy making? Public Admin Rev. 2016 May/Jun;76(3):472–84 https://doi.org/10.1111/puar.1247
3. Oxman AD, Lavis JN, Fretheim A. Use of evidence in WHO recommendations. Lancet (London, England). 2007 Jun 2;369(9576):1883–9. https://doi.org/10.1016/S0140-6736(07)60675-8 PMID:17493676
4. Developing national institutional capacity for evidence-informed policy-making for health. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2019 (EM/RC66/R.5; https://applications.emro.who.int/docs/RC66-R5-eng.pdf?ua=, accessed 221 March 2023).
5. Kuchenmüller T, Lavis J, Kheirandish M, Reveiz L, Reinap M, Okeibunor J, et al. Time for a new global roadmap for supporting evidence into action. PLOS Glob Public Health. 2(6):e0000677. https://doi.org/10.1371/journal.pgph.0000677
6. Lester L, Haby MM, Chapman E, Kuchenmüller T. Evaluation of the performance and achievements of the WHO Evidence-informed Policy Network (EVIPNet) Europe. Health Res Policy Syst. 2020 Sep 24;18(1):109. https://doi.org/10.1186/s12961-020-00612-x PMID:32972421
7. Using research evidence for policy-making: evidence briefs for policy. Virtual meeting for countries from Eastern Europe and Central Asia: report of the introductory session, 6 October 2020. Copenhagen: World Health Organization Regional Office for Europe; 2021 (WHO/EURO: 2021-2017-41772-57224; https://apps.who.int/iris/handle/10665/339783, accessed 21 March 2023).
8. Wilson MG LJ, Gauvin F-P. Issue Brief: developing a ‘rapid-response’ program for health system decision-makers in Canada. Hamilton: McMaster Health Forum, 7 March 2014. https://macsphere.mcmaster.ca/handle/11375/14877
9. COVID-19 strategic preparedness and response plan (SPRP 2021). Geneva: World Health Organization; 2021 (https://www.who.int/publications-detail-redirect/WHO-WHE-2021.02, accessed 15 April 2023).
10. Preparedness and response for the control of COVID-19 in the Islamic Republic of Iran. Tehran: Ministry of Health and Medical Education; 2020.
11. Khalagi K, Gharibzadeh S, Khalili D, Mansournia MA, Mirab Samiee S, Aghamohamadi S, et al. Prevalence of COVID-19 in Iran: results of the first survey of the Iranian COVID-19 Serological Surveillance programme. Clin Microbiol Infect. 2021 Nov;27(11):1666–71.
https://doi.org/10.1016/j.cmi.2021.06.002 PMID:34111585
