News of the outbreak of an unknown virus in Wuhan, China, quickly caught the attention of South African disease experts in December 2019. In the event the virus spread globally, those experts understood that the South African government would find itself face to face with two persistent challenges. First, although an upper-middle-income country, South Africa was also the world’s most unequal. Within the country, household access to health care varied dramatically, as did the vulnerability of livelihoods to economic shocks. Second, there were wide disparities in the levels of readiness across the provinces, districts, and cities that would manage the front lines of any response. During mid-March 2020, as the first South African residents fell ill, the government set up a structure for making policy decisions. It vested responsibility for pandemic response coordination in the security services, implemented stringent restrictions on movement, and used the country’s natural disaster management system to try to align policy with the provinces. The Department of Health, already focused on disease surveillance, testing, and other technical functions, cochaired many of the work streams in those institutions. Nonetheless, during the first wave, poorer provinces and districts struggled to respond effectively, and the national government—with external help—surged assistance to those areas. The investment helped contain the spread of infection and return the country to lower alert levels, but disparities in capacity, illness, and deaths persisted in subsequent waves. The country continued to adapt and performed better on several metrics than did a number of similarly situated counterparts. However, the experience pinpointed the difficulties of boosting local preparedness and addressing underlying inequalities amid a crisis.

Jennifer Widner and Andile Cele drafted this case study based on interviews conducted in South Africa during 2021. Tyler McBrien assisted with some of the background research. Case published March 2024.

In mid-2020, Tunisia stood out as a star within its region. The first wave of the COVID-19 pandemic had taken a high toll in the Middle East and North Africa. But by the end of the second week of August, as the first wave ebbed, Tunisia had recorded 149 cumulative cases per million people—compared with more than 800 per million in Algeria, Egypt, Morocco, and most of the rest of the region. Tunisia’s epidemic curve was almost flat. However, the good news was short-lived. By mid-August, the number of COVID-19 cases had started to rise, and by October the number of cases per million in Tunisia matched that of other countries in the area. A year later, Tunisia was a regional hot spot. This case study profiles the difficulty of containing the spread of disease when local governments are new and have limited capacity, when public health guidance from a national government modulates or weakens, and when political distrust runs high.

Mariam Ghanem and ISS staff researched and wrote this case based on research conducted during May, June, and July 2021. Case published January 2022. This case study was supported by the United Nations Development Programme Crisis Bureau as part of a series on center-of-government coordination of the pandemic response.

The views expressed in this publication are those of the author(s) and do not necessarily represent those of the United Nations, including UNDP, or the UN Member States.

Despite having a sophisticated health-care system and spending more on health care than do most countries in the world, by the early 2010s the Netherlands experienced some of the poorest perinatal-health outcomes in the European Union. Birth-related complications among women and infants were driven primarily by economic and social inequality. For example, women living in the country’s low-income neighborhoods were up to four times more likely to die during childbirth than the Dutch average. In partnership with university researchers, the municipalities of Rotterdam, Groningen, and Tilburg began tackling the problem. After discovering that the growing disparities in perinatal health outcomes were driven in large part by social and economic challenges rather than by purely medical factors, the cities set out to build integrated, multisectoral teams­—local coalitions—that brought together service providers working in both the health-care and social domains. To tailor care to an individual patient’s own circumstances, the coalitions transcended the traditional boundaries that separated physicians, midwives, municipal officials, social workers, and other service providers. They worked to integrate their records and come to agreement on ways to monitor progress, and they designed referral systems and procedural road maps to deal with specific and individual client problems. In 2018, the national Ministry of Health, Welfare and Sport expanded the use of such local coalitions to reduce early-childhood health disparities in municipalities throughout the country. By early 2022, 275 of the Netherlands’ 345 municipalities were participating in the program, dubbed Solid Start, and the new national government pledged to expand the program to every municipality in the country.

Leon Schreiber drafted this case study based on interviews conducted between September 2021 and April 2022. Case published May 2022. This case study was supported by Bernard van Leer Foundation as part of a policy learning initiative. Please note that the Solid Start program described in the case is not an instance of the foundation’s Urban95 strategy, which features in several other ISS case studies that are part of the learning project.

In early January 2020, when the World Health Organization announced that SARS-CoV-2 had spread beyond Wuhan, China, and represented a public health risk of international concern, Costa Rica was better prepared than other countries in its region. The Central American nation had years earlier developed preparedness and response plans to deal with swine flu, avian flu, Ebola, and other infectious diseases and had updated them in 2018. There was high confidence in both the country’s universal health-care system and the government health-care teams that served even the remotest regions of the country. Doctors had access to an up-to-date database of medical histories that covered more than three-quarters of the population of about 5 million. However, the country also had some vulnerabilities: more than a fifth of the populace lived in poverty; many jobs were associated with international tourism—a sector likely to be hit hard in a pandemic; and the government was wrestling with a fiscal crisis that had started years earlier. Weeks before Costa Rica confirmed its first case of COVID-19, ministries and national institutions began work to procure medical supplies and equipment, set up financial and social assistance programs, and develop a road map to build resilience for the tourism industry. When the virus appeared in early March, the national government declared a state of emergency within days to ensure that every ministry and institution could contribute effectively to the pandemic response. Initial confirmed infections were relatively low in number, but as case numbers grew through 2020, collaborations with partners both national and international led to innovative solutions to avoid a nationwide lockdown and make Costa Rica the first country in Latin America to safely reactivate commercial air travel and international tourism before year’s end.

Miguelángel Verde researched and wrote this case based on interviews conducted during August, September, October, and November 2021. Case published January 2022. This case study was supported by the United Nations Development Programme Crisis Bureau as part of a series on center-of-government coordination of the pandemic response.

The views expressed in this publication are those of the author(s) and do not necessarily represent those of the United Nations, including UNDP, or the UN Member States.

When Africa’s most populous country, Nigeria, confirmed its first case of COVID-19, President Muhammadu Buhari tapped the former head of the country’s HIV/AIDS control program, Dr. Sani Aliyu, to design the country’s COVID-response coordination system. Aliyu’s coproduction model partnered Nigerian government experts with United Nations agencies and other organizations that had essential capacities and gave each of them with specific roles. Because Nigeria’s federal system of government endowed the states with major responsibility for public health, Aliyu’s team worked to support governors and state-level emergency operations. The team soon realized that lockdowns were very difficult to maintain in a country where most households depended on income from the informal sector, so it employed a hot-spot strategy in lieu of nationwide lockdowns. To help fine-tune the response, the team conducted weekly national polls to assess residents’ knowledge, perceptions, and behaviors and then adjusted its messages to secure greater compliance with safety measures. Gradually, the government also reached several million vulnerable households with social and economic support. Nigeria ended the first year of the pandemic without repeated surges in serious cases requiring medical care, and it was able to close many of the temporary treatment centers it had set up.

Emily Tenenbom and staff drafted this case study based on interviews conducted during August and September 2021. Bunmi Makinwa assisted. Case published January 2022. This case study was supported by the United Nations Development Programme Crisis Bureau as part of a series on center-of-government coordination of the pandemic response.

The views expressed in this publication are those of the author(s) and do not necessarily represent those of the United Nations, including UNDP, or the UN Member States.

When the first case of COVID-19 reached Germany in January 2020, the country’s world-class medical and scientific institutions snapped into action to contain—and learn from—an outbreak in Bavaria. As the pandemic escalated, Chancellor Angela Merkel, a scientist by training, based the government’s response on epidemiological models and expert advice. But Germany’s strictly federalized political system reserved power for the 16 states, not the central government. To coordinate the kind of nationwide response needed to curb the spread of the virus, Merkel’s government developed new coordination bodies that harmonized physical-distancing policies across the country. After a nationwide lockdown slowed the initial spread, a response model of federal government guidance and support but with decentralized, local implementation enabled Germany to quickly ramp up both testing and contact-tracing capacities. As a result, from January through October 2020, Germany contained the virus more effectively than any large country in Europe or North America. At year’s end, however, political consensus about how to respond to the virus broke down. With a vaccine on the horizon and the public tired of lockdowns, states hesitated to reimpose restrictions, and new infections surged.

Gordon LaForge drafted this case study based on interviews conducted in February 2021. Case published October 2021.

When SARS-CoV-2 began spreading in Colombia in mid-March 2020, the national government feared the worst: a collapse of the health system. In response, President Iván Duque Márquez ordered the strictest nationwide lockdown in the Western Hemisphere. To implement the lockdown, the national government centralized authority, coordinated a trial run in the city of Bogotá, and relied on epidemiological data from an updated reporting system. The lockdown curbed the initial spread of the virus and bought the government time to increase intensive-care capacity. But the shutdown of the economy threatened to push millions in Colombia’s informal sector into poverty. The government rapidly expanded the social safety net, which nearly doubled the total number of welfare beneficiaries. It also took steps to provide assistance for the highly vulnerable population of 1.8 million Venezuelan migrants in the country. As the lockdown continued into its third month, the high socioeconomic costs of isolation and the government’s lack of consultation with municipalities, which were heterogeneous and were each affected differently by the virus, led to a breakdown in compliance. By the end of the year, new daily infections were at all-time highs, and though the government had kept millions out of poverty, social unrest loomed.

Gordon LaForge drafted this case study based on interviews conducted with the assistance of Miguelangel Verde in May, June, and July 2021. Case published September 2021.This case study was supported by the United Nations Development Programme Crisis Bureau as part of a series on center-of-government coordination of the pandemic response.

The views expressed in this publication are those of the author(s) and do not necessarily represent those of the United Nations, including UNDP, or the UN Member States.

Senegal entered the COVID-19 pandemic with what seemed to be grave disadvantages, among them the inability of most households to adjust to prolonged lockdowns, given their dependence on wages they earned day to day. But the West African country also enjoyed an advantage: it was well prepared for an epidemic. In the years following the 2014 Ebola outbreak, Senegal had built a comprehensive health-care emergency response system, and when COVID-19 arrived in March 2020, Senegal moved fast. President Macky Sall declared a state of emergency and announced immediate restrictions to limit the spread of the virus. The country’s emergency operations center became the headquarters for a dedicated COVID-19 Incident Management System, and the Dakar branch of the international Pasteur Institute helped develop a rapid diagnostic test. The government spent 7% of its gross domestic product—more than any other country in Africa—on socioeconomic support measures. The response team credited those measures with the successful containment of community spread during the first wave of the disease. During 2020, the numbers of ill people coming to hospitals and health facilities for treatment remained low, and disease models suggested that subsequent waves were generally of short duration—even after an October religious pilgrimage that had brought thousands together under crowded conditions.

Leon Schreiber and Matthew Schofield drafted this case study based on interviews conducted with the help of Placide Muhigana in February, March, and June 2021. Case study published August 2021. This case study was supported by the United Nations Development Programme Crisis Bureau as part of a series on center-of-government coordination of the pandemic response.

The views expressed in this publication are those of the author(s) and do not necessarily represent those of the United Nations, including UNDP, or the UN Member States.

When SARS-CoV-2 emerged in Wuhan, China, in late 2019, Vietnam’s scientists knew their country was in grave danger. Vietnam, a country of 97 million, shared an 870-mile land border with China, its biggest trade and tourism partner. Adding to the risk posed by the virus, Vietnam was a lower-middle-income nation with limited resources and an already overtaxed health-care system. But in the years after the 2003 outbreak of SARS, a deadly respiratory ailment that traumatized East Asia, Vietnam had built a robust pandemic-preparedness system that swiftly mobilized to confront the threat of SARS-CoV-2. After Vietnam recorded its first case on January 22, 2020, the prime minister declared all-out war on the virus no matter the cost to the economy. The government moved swiftly to implement border closures, extensive contact tracing, targeted lockdowns, and a strict quarantine protocol. Relentless and creative communications based on accuracy, transparency, and timeliness built public trust and compliance with public health measures. After more than three months with no community transmission, the country experienced an outbreak in Da Nang that spread across the nation and threatened to spiral out of control. But Vietnam’s authorities carried out a massive testing, tracing, and quarantine program that halted the contagion. As of December 31, 2020, Vietnam had recorded only 1,465 cases and 35 deaths—and it had posted the highest annual GDP growth of any economy in Asia.

Gordon LaForge drafted this case study based on interviews conducted in March and April 2021. Case published June 2021.This case study was supported by the United Nations Development Programme Crisis Bureau as part of a series on center-of-government coordination of the pandemic response.

The views expressed in this publication are those of the author(s) and do not necessarily represent those of the United Nations, including UNDP, or the UN Member States.

In 2017, Geraldo Julio, the mayor of Recife, Brazil, heard scientific evidence that ensuring children from birth to age six years got a better start in life resulted in long-term benefits such as improved health, more-effective learning, less likelihood of criminal involvement, and increased employability. Julio, a technically-oriented leader in his second and final term, saw investment in early childhood development as an innovative strategy for addressing chronic crime and economic inequality in some of the city’s toughest neighborhoods. To enable parents and young children to move more safely and more quickly to locations where they could find efficiently clustered resources would require the city to align efforts in several city departments, including parks, public works, health, and education. Julio set up a management team and a steering committee to guide that work and won passage of legislation that authorized him to devote municipal resources and grant funding from private groups to the new strategy. The city engaged an existing public–private urban planning partnership to launch and manage pilot projects in two poor but contrasting neighborhoods: one where homes clung to steep, slide-prone hillsides and another where many residents lived in stilt houses on flood-prone riverbanks. It collaborated with a community peace center that could reach target neighborhoods effectively. Further, the mayor’s teams helped municipal departments start projects that would support the new agenda. In mid 2019, nearly two years after the program began, the pilot projects yielded key lessons about how to improve access to services for families with young children. 

Bill Steiden drafted this case study with the help of Sam Dearden based on interviews conducted in Recife, Brazil, in March and May 2019. Case published June 2019. The Bernard van Leer Foundation sponsored this case study, which is part of a series, to support learning in the early stages of its Urban95 program. Savvas Verdis and Philipp Rodeof the London School of Economics served as independent reviewers.