Decisive leadership is a necessity in the COVID-19 response.

The COVID-19 pandemic poses one of the greatest threats in recent human history as the virus has spread rapidly worldwide, affecting the lives and livelihoods of billions. As of June 30, 2020, according to WHO, more than 1 million cases of COVID-19 had been confirmed in its Eastern Mediterranean Region (EMR) alone, with considerable differences in the scale and progression of the pandemic in different countries. With national governments at the forefront of response and mixed reactions displayed by political and public health leaders, decisive leadership is emerging as a key factor in determining success.

Examples of effective responses around the world and in the EMR include rapid response, good coordination, an evidence-based approach that is well communicated, and partnership spirit. Numerous factors have been proposed to account for the variation in the numbers of COVID-19 cases and deaths relative to population. For example, the disparities in health system capacities must be acknowledged, although the pandemic has even overwhelmed some countries with advanced capacities. Demographics could be important, with the high numbers of cases and deaths in Italy possibly partly due to an elderly population and high prevalence of comorbidities, as well as cultural factors such as high levels of socialisation, which might influence compliance with public health measures. Nevertheless, the role of leadership in pandemic response remains undeniable.

A recognised characteristic of decisive leadership is rapid response, based on a clear understanding of the threat posed by COVID-19 and that delayed action could lead to worse outcomes. In a study of national responses, there was substantial variation in the rate and speed at which stricter measures were adopted. Even for similar lockdown measures, earlier implementation was associated with better outcomes. In Germany and New Zealand, leaders have been praised for their decisive action. Some have attributed the success of these countries to their female leaders. Meanwhile, the Jordanian Government suspended study in educational institutions and stopped religious gatherings in places of worship within 12 days of its first case.

Effective leaders ensure good coordination, given the socioeconomic and health dimensions of the pandemic. Learning from previous disease outbreaks, Singapore established a multiministry taskforce to centrally coordinate a whole-of-government response before it had any confirmed cases. The creation of the National COVID-19 Monitoring Authority in Tunisia has brought together senior officials from all ministries to ensure compliance with measures across sectors, as well as coordination between regional and national committees. The Lebanese Government has developed a COVID-19 response plan that involves the private as well as the public sector. Decentralised systems have at times been identified as a problem, although this may only be when combined with poor communication; despite initial delays, Switzerland has shown the effectiveness of mutual learning and integration between local decentralised approaches in its response to COVID-19.

Science guides decisive and impactful actions by leaders in countries where success is being recorded in the COVID-19 response. Implementation of large-scale lockdown measures has substantially reduced the number of COVID-19 cases—eg, estimates suggest that 2·1 million more COVID-19 cases have been avoided in Italy because of lockdown measures. Establishing testing capacity was part of the first stage of South Africa's response, and after easing of its national lockdown, contact tracing teams for tuberculosis control were redirected to proactive COVID-19 case finding, contact tracing, and monitoring quarantine compliance, which has resulted in community-based screening of almost 20% of the population. Ultimately, given that high-quality disease surveillance data are sometimes not readily available, decisions should be based on best available knowledge, while adapting to new information.

Decisive leadership appreciates the need for trusted public communication. Although government action is necessary to implement wide-scale measures, individual behaviour rather than governmental action is also important in limiting the spread of COVID-19, with emphasis on the importance of ensuring individual rights.14, 15 In Jordan and Morocco, for example, the governments have harnessed the potential of information technology to set up a website and app for epidemiological information and surveillance. Building trust requires clear and consistent communication based on reliable sources, thus promoting transparency and accountability. Political partisanship negatively affects health behaviours and policy preferences, thus impacting success or failure of the COVID-19 response. Factors that undermine trust such as political polarisation should be deliberately addressed by leaders. Effective communication needs to emphasise a shared identity against the COVID-19 threat.

Finally, effective leaders believe in a partnership-driven solidarity response to the pandemic. It starts with adherence to the measures defined by the International Health Regulations (2005). Transparency in sharing data is crucial, as shown by South Korea, which shared relevant information with agencies such as WHO from its first confirmed case. More countries have shown solidarity in financial support, donations of medical supplies, and sharing expertise at this time of unprecedented crisis. Saudi Arabia, for example, has donated financially to pandemic response efforts, while Cuba has sent doctors to other countries to support their response. Partnership among countries is essential for obtaining faster results in COVID-19 treatment and vaccine clinical trials and WHO is supporting global partnerships through its Solidarity Fund, COVID-19 Supply Chain System, and Solidarity Trial.21, 22 A pandemic that presents a global threat requires all leaders to step up and cooperate in decisive action.

In the months to come, in the EMR and beyond, our sustained effort to save lives and mitigate the socioeconomic impact of COVID-19 must promote the role of decisive, open, and compassionate leadership. In countries where large numbers of infections are still being reported, it is time that leaders acknowledge the importance of rapidly acting on the best available evidence with transparency, a responsibility that is particularly crucial in low-income and fragile settings. Leaders must act decisively in the COVID-19 response with whole-of-government and whole-of-society approaches.