Modeling the barriers to multistakeholder collaboration for COVID-19 pandemic response: Evidence from Sub-Saharan Africa

Figures & data

Table 1. Identification and classification of barriers to successful collaboration.

S. No	Barriers	Themes	Research Studies
1.	Funding constraints	Improper funding, resource limitation, fluctuating funding priorities, lack of resources to train partners, limited resource commitment over time	Cruz (2014); Bennett and Carney (2011); Bevc et al. (2014); Goering et al. (2003); Mac McCullough, Eisen-Cohen, and Lott (2020)
2.	Ineffective resource management and allocation	Resource management and allocation, lack prioritization of resources	Santibañez et al. (2017); Pratt et al. (2018)
3.	Differences in organizational culture, working habits and priorities	Differences in organizational culture and working habits, divergent organizational cultures, and preferences	Pratt et al. (2018); Dunlop et al. (2016)
4.	Trust issues	Lack of trust and members’ self-interest, absence of partner’s commitment and loyalty	Cruz (2014); Mac McCullough, Eisen-Cohen, and Lott (2020); Goering et al. (2003)
5.	Leadership challenges	Leadership style, lack of direction from the leadership, leader’s inability to equitably disseminate incentives to team members, unethical priority setting, gaps in awareness of the chain of command, inadequate directive (guidance), breakdown in administrative accountability, poor coordination, variation in the planning process, overlap and duplication of team responsibilities, lack of clarity about coordinating roles and responsibilities, absence of clarity about mutual expectations	Lai (2012); Shoaf et al. (2014); Mays and Scutchfield (2010); Bennett and Carney (2011); Dalnoki-Veress, McKallagat, and Klebesadal (2014); Bevc et al. (2014); Koliba, Mills, and Zia (2011); Nick et al. (2009); Cruz (2014); de Vries et al. (2019); Goering et al. (2003)
6.	Lack of a proper governance framework for the decision-making process	Lack of clarity on the governance and decision-making structure, absence of shared decision making	Paige et al. (2010); Goering et al. (2003)
7.	Poor and ineffective communication	Lack of communication, information transfer and communication failures, informal style of communication, communication issues around data sharing, difficulties in tracking down information, lack of clarity in information transferred between collaborators, absence of regular consultation with public health officials	Goering et al. (2003); Pratt et al. (2018); Lai (2012); Paige et al. (2010); Cruz (2014); Nick et al. (2009); Dalnoki-Veress, McKallagat, and Klebesadal (2014); Christensen and Laegreid (2020)
8.	Overworked teams	Team members are pressurized for additional commitment (overwork)	Shoaf et al. (2014)
9.	Relationship-building and networking issues	Non-supportive collaborative environment, misalignment of interests, lack of networking capabilities	Goering et al. (2003); Cruz (2014); Lai (2012)
10.	Ownership of project benefits and success	Concerns around ownership of outputs or results, raised expectations about the benefits of collaboration	Dunlop et al. (2016); Mac McCullough, Eisen-Cohen, and Lott (2020);
11.	Maintenance of individual (organizational) autonomy while co-operating with others	Perceived loss of organizational autonomy	Shoaf et al. (2014)
12.	Lack of guidelines, blueprints, or procedures for coordinated actions	Lack of guidelines or blueprints for coordinated preparedness actions, inconsistencies of processes, absence of a quality control mechanism	Swaan et al. (2018); Paige et al. (2010); Goering et al. (2003)
13.	Data management constraints (data collection, analysis, and integration)	Disconnects between planning priorities and vulnerability data, inability to locate vulnerable populations, integration of data into the nationwide emergency plan, lack of confidence in the use of surveillance technology	Bevc et al. (2014); Nick et al. (2009); Nick et al. (2009); Bennett and Carney (2011)
14.	Legal issues	Copyright infringement, intellectual property issues	Paige et al. (2010)
15.	High opportunity costs	High opportunity costs (loss of potential gain from other alternatives when one alternative is selected)	Mays and Scutchfield (2010)

Figure 1. Stages of the application of the ISM methodology.

Table 2. Profiles of the selected experts.

Expert	Type of Organization	Designation	Country	Years of experience
1.	NGO	Senior Manager	Cameroun	13
2.	Security services	Officer	Cameroun	10
3.	Government agency	Public Servant	Kenya	11
4.	Healthcare facility	Medical Doctor	Kenya	15
5.	Supplier (health products)	Manager	Kenya	6
6.	NGO	Country Representative	Zambia	30
7.	Healthcare facility	Nurse	Zambia	9
8.	Government agency	Public Servant	Nigeria	19
9.	Security services	Officer	Nigeria	14
10.	Academic institution	Professor	Nigeria	10
11.	Academic institution	Research Fellow	UK	6
12.	Academic institution	Professor	UK	25
13.	Academic institution	Research Fellow	UK	5

Table 3. Experience of the barriers in the context of the COVID-19 pandemic.

Barriers	Perceived Importance in the Context of the COVID-19 Pandemic	Sample Comments from the Experts
1. Funding constraints	High	“There was anxiety on how to reallocate funding that had already been committed to other programmes; hence, government readiness to collaborate was low.”
2. Ineffective resource management and allocation	Moderate	“[Resource allocation] is not so much of a problem or a headache because we have a resource mobilization team that is key to the task force. However, the stakeholders have noticed that once the goods are handed to the government, misallocations [occur].”
3. Differences in organizational culture, working habits and priorities	High	“This [barrier] has a considerable impact; organizations that want to support the said governments must use the funding for their priorities (e.g. ventilators might not be a country’s priority).”
4. Trust issues	High	“The potential to divert money for COVID-19 into other issues might affect the outcome of the project.”
5. Leadership challenges	Moderate	“[This barrier] is not an issue; there is a leadership structure in each country for COVID-19 preparedness and response both from the Ministry of Health and other sectors or stakeholders. However, the internal operationalization of the leadership structure is an issue, which makes it increasingly difficult to function in the collaboration because weak systems are used to inform [such] collaboration.”
6. Lack of a proper governance framework for the decision-making process	Moderate	“Countries have governance frameworks on reporting for COVID-19 collaborative response, but their supply chains present a significant challenge. Thus, [it is incumbent upon] individual leaders to make decisions concerning the supply chain, given the lack of a specifically directed governance structure for the supply chain, which is a barrier to collaboration.”
7. Poor and ineffective communication	Moderate	“There are communication and engagement strategies (e.g. escalation, clarifications where needed) that are useful. [Certain] parameters for information must be collected and communicated as instituted by WHO.”
8. Overworked teams	Moderate	“People are stressed and tired, but the impact on collaboration outcomes is not visible.”
9. Relationship-building and networking issues	Moderate	“Relationship networks already exist between different stakeholders, which are established through regular consultation. The problem is when the private sector is brought in to support the planning: it took them an enormous amount of time before they started networking with other members.”
10. Ownership of project benefits and success	Low	“Benefits and ownership always belong to the Ministry of Health; the joint sharing of ownership of success [transpires] because partners know that the collaboration is in the best interest of everyone and for COVID-19 mitigation.”
11. Maintenance of individual (organizational) autonomy while co-operating with others	Low	“Sometimes people may differently undertake priority actions on health programme elements. Nonetheless, every country has a national technical working group consisting of autonomous bodies that do their work in collaboration with the NCDC.”
12. Lack of guidelines, blueprints, or procedures for coordinated actions	High	“There is a general lack of structure or procedure in place to guide collaborative actions. However, as the COVID-19 [pandemic] continues, task force members are developing templates to oversee operations.”
13. Data management constraints (data collection, analysis and integration)	High	“Countries have been using existing (resource) systems that do not provide the kind of efficient and accurate data expected. This [factor] is now becoming critical, as the information being generated is fragmented and lacking in harmonization. The fact that people do not trust the data they have makes the collaboration difficult.”
14. Legal issues	High	“Regulatory issues initially do not appear to matter. However, as time goes on, they affect the collaborative effort to respond to the COVID-19 crisis. This [case] happens in terms of the involvement of the private sector, in which governments are procuring health products that are not under the WHO commodities. For example, so many sanitizers [are sold] in the market, but standards are lacking.”
15. High opportunity costs (loss of potential gain from other alternatives when one alternative is chosen)	High	“For example, a decision is made to go with one funder for procurement. However, a realization later occurs regarding the alternative collaborators’ potential to offer more advantages in terms of what should have been procured.”

Table 4. Differential rating scale.

Strength of the relation	No	Very low	Low	Medium	High	Very high	Full
Notation	O	VL	L	M	H	VH	F
Value	0	0.1	0.3	0.5	0.7	0.9	1

Table 5. Structural self-interaction matrix.

Barriers	15	14	13	12	11	10	9	8	7	6	5	4	3	2	1
1. Funding constraints	VH	O	F	O	O	O	O	O	O	O	O	O	O	H	–
2. Ineffective resource management and allocation	H	O	F	F	O	O	O	O	M	F	H	M	H	–
3. Differences in organizational culture, working habits and priorities	F	H	H	O	F	F	F	H	H	H	M	F	–
4. Trust issues	O	F	M	H	F	F	H	O	F	M	F	–
5. Leadership challenges	M	O	O	H	H	F	M	H	H	F	–
6. Lack of a proper governance framework for the decision-making process	M	F	M	H	H	H	F	O	F	–
7. Poor and ineffective communication	O	O	M	F	O	M	H	O	–
8. Overworked teams	H	O	M	F	M	O	O	–
9. Relationship-building and networking issues	O	O	O	H	H	M	–
10. Ownership of project benefits and success	O	O	H	F	M	–
11. Maintenance of individual (organizational) autonomy while co-operating with others	O	M	M	M	–
12. Lack of guidelines, blueprints or procedures for coordinated actions	F	F	F	–
13. Data management constraints (data collection, analysis and integration)	O	H	–
14. Legal issues	VH	–
15. High opportunity costs (loss of potential gain from other alternatives when one alternative is chosen)	–

(*Color Codes: Black color: Direct link; Sandal color: Reverse relationship; Red color: Mutual relationship; Blue color: No relationships)

Table 6. Initial reachability matrix.

Barriers (B)	B1	B2	B3	B4	B5	B6	B7	B8	B9	B10	B11	B12	B13	B14	B15
B1	1	0.7	0	0	0	0	0	0	0	0	0	0	1	0	0.9
B2	0	1	0	0.5	0.7	0	0.5	0	0	0	0	0	0	0	0
B3	0	0.7	1	1	0.5	0	0.7	0.7	1	1	1	0	0.7	0.7	1
B4	0	0	0	1	1	0.5	1	0	0.7	1	1	0	0.5	1	0
B5	0	0.7	0	1	1	1	0.7	0.7	0.5	1	0.7	0	0	0	0.5
B6	0	1	0.7	0.5	1	1	1	0	1	0.7	0.7	0.7	0.5	1	0.5
B7	0	0.5	0	1	0.7	0	1	0	0.7	0.5	0	0	0.5	0	0
B8	0	0	0	0	0	0	0	1	0	0	0	0	0	0	0
B9	0	0	0	0.7	0.5	0	0.7	0	1	0	0.7	0	0	0	0
B10	0	0	0	1	0	0	0	0	0.5	1	0.5	0	0.7	0	0
B11	0	0	0	1	0.7	0	0	0.5	0.7	0.5	1	0	0.5	0.5	0
B12	0	1	0	0.7	0.7	0.7	1	1	0.7	1	0.5	1	1	1	1
B13	0	1	0	0	0	0	0.5	0.5	0	0	0	0	1	0	0
B14	0	0	0	1	0	0	0	0	0	0	0	0	0.7	1	0.9
B15	0	0.7	0	0	0	0.5	0	0.7	0	0	0	0	0	0	1

Table 7. Final reachability matrix.

Barriers (B)	B1	B2	B3	B4	B5	B6	B7	B8	B9	B10	B11	B12	B13	B14	B15	Driving Power
B1	1	0.7	0	0.3*	0.3*	0.3*	0.1*	0.3*	0	0	0	0	1	0	0.9	4.9
B2	0	1	0	0.5	0.7	0.3*	0.5	0.3*	0.3*	0.1*	0.3*	0	0.1*	0.3*	0.3*	4.7
B3	0	0.7	1	1	0.5	0.3*	0.7	0.7	1	1	1	0	0.7	0.7	1	10.3
B4	0	0.3*	0.3*	1	1	0.5	1	0.3*	0.7	1	1	0.3*	0.5	1	0.3*	9.2
B5	0	0.7	0.3*	1	1	1	0.7	0.7	0.5	1	0.7	0.3*	0.3*	0.3*	0.5	9
B6	0	1	0.7	0.5	1	1	1	0.3*	1	0.7	0.7	0.7	0.5	1	0.5	10.6
B7	0	0.5	0	1	0.7	0.3*	1	0.3*	0.7	0.5	0.3*	0	0.5	0.3*	0.3*	6.4
B8	0	0	0	0	0	0	0	1	0	0	0	0	0	0	0	1
B9	0	0.3*	0	0.7	0.5	0.5*	0.7	0.3*	1	0.3*	0.7	0	0.3*	0.3*	0.3*	5.9
B10	0	0.3*	0	1	0.3*	0.5*	0.3*	0.3*	0.5	1	0.5	0	0.7	0.3*	0	5.7
B11	0	0.3*	0	1	0.7	0.5*	0.3*	0.5	0.7	0.5	1	0	0.5	0.5	0.3*	6.8
B12	0	1	0.3*	0.7	0.7	0.7	1	1	0.7	1	0.5	1	1	1	1	11.6
B13	0	1	0	0.3*	0.3*	0.3*	0.5	0.5	0.3*	0.3*	0.3*	0	1	0	0	4.8
B14	0	0.3*	0	1	0.3*	0.3*	0.3*	0.3*	0.3*	0.3*	0.3*	0	0.7	1	0.9	6
B15	0	0.7	0.3*	0.3*	0.3*	0.5	0.3*	0.7	0.3*	0.3*	0.3*	0.3*	0.3*	0.3*	1	5.9
Dependence Power	1	8.8	2.9	10.3	8.3	7	8.4	7.5	8	8	7.6	2.6	8.1	7	7.3

Table 8. Level partitions for the barriers.

Barriers (B)	Reachability Set	Antecedent Set	Intersection Set	Level
B1	1,2,4,5,6,7,8,13,15	1	1	VI
B2	2,4,5,6,7,8,9,10,11,13,14,15	1,2,3,4,5,6,7,9,10,11,12,13,14,15	2,4,5,6,7,9,10,11,12,13,14,15	II
B3	2,3,4,5,6,7,8,9,10,11,13,14,15	3,4,5,6,12,15	3,4,5,6,15	I V
B4	2,3,4,5,6,7,8,9,10,11,12,13,14,15	1,2,3,4,5,6,7,9,10,11,12,13,14,15	2,3,4,5,6,7,9,10,11,12,13,14,15	II
B5	2,3,4,5,6,7,8,9,10,11,12,13,14,15	1,2,3,4,5,6,7,9,10,11,12,13,14,15	2,3,4,5,6,7,9,10,11,12,13,14,15	II
B6	2,3,4,5,6,7,8,9,10,11,12,13,14,15	1,2,3,4,5,6,7,9,10,11,12,13,14,15	2,3,4,5,6,7,9,10,11,12,13,14,15	II
B7	2,4,5,6,7,8,9,10,11,13,14,15	1,2,3,4,5,6,7,9,10,11,12,13,14,15	2,4,5,6,7,9,10,11,13,14,15	II
B8	8	1,2,3,4,5,6,7,8,9,10,11,12,13,14,15	8	I
B9	2,4,5,6,7,8,9,10,11,13,14,15	2,3,4,5,6,7,9,10,11,12,13,14,15	2,4,5,6,7,9,10,11,13,14,15	II
B10	2,4,5,6,7,8,9,10,11,13,14	2,3,4,5,6,7,9,10,11,12,13,14,15	2,4,5,6,7,9,10,11,13,14	II
B11	2,4,5,6,7,8,9,10,11,13,14,15	2,3,4,5,6,7,9,10,11,13,12,14,15	2,4,5,6,7,9,10,11,13,14,15	II
B12	2,3,4,5,6,7,8,9,10,11,12,13,14,15	4,5,6,12,15	4,5,6,12,15	V
B13	2,4,5,6,7,8,9,10,13	1,2,3,4,5,6,7,9,10,11,12,13,14,15	2,4,5,6,7,9,10,11,13	II
B14	2,4,5,6,7,8,9,10,11,13,14,15	2,3,4,5,6,7,9,10,11,12,14,15	2,4,5,6,7,9,10,11,14,15	III
B15	2,3,4,5,6,7,8,9,10,11,12,13,14,15	1,2,3,4,5,6,7,9,11,12,14,15	2,3,4,5,7,9,11,12,14,15	III

Table 9. Canonical form of the final reachability matrix.

Barriers (B)	B1	B2	B3	B4	B5	B6	B7	B8	B9	B10	B11	B12	B13	B14	B15	Level
B8	0	0	0	0	0	0	0	1	0	0	0	0	0	0	0	I
B2	0	1	0	0.5	0.7	0.3	0.5	0.3	0.3	0.1	0.3	0	0.1	0.3	0.3	II
B4	0	0.3	0.3	1	1	0.5	1	0.3	0.7	1	1	0.3	0.5	1	0.3	II
B5	0	0.7	0.3	1	1	1	0.7	0.7	0.5	1	0.7	0.3	0.3	0.3	0.5	II
B6	0	1	0.7	0.5	1	1	1	0.3	1	0.7	0.7	0.7	0.5	1	0.5	II
B7	0	0.5	0	1	0.7	0.3	1	0.3	0.7	0.5	0.3	0	0.5	0.3	0.3	II
B9	0	0.3	0	0.7	0.5	0.5	0.7	0.3	1	0.3	0.7	0	0.3	0.3	0.3	II
B10	0	0.3	0	1	0.3	0.5	0.3	0.3	0.5	1	0.5	0	0.7	0.3	0	II
B11	0	0.3	0	1	0.7	0.5	0.3	0.5	0.7	0.5	1	0	0.5	0.5	0.3	II
B13	0	1	0	0.3	0.3	0.3	0.5	0.5	0.3	0.3	0.3	0	1	0	0	II
B14	0	0.3	0	1	0.3	0.3	0.3	0.3	0.3	0.3	0.3	0	0.7	1	0.9	III
B15	0	0.7	0.3	0.3	0.3	0.5	0.3	0.7	0.3	0.3	0.3	0.3	0.3	0.3	1	III
B1	1	0.7	0	0.3	0.3	0.3	0.1	0.3	0	0	0	0	1	0	0.9	IV
B3	0	0.7	1	1	0.5	0.3	0.7	0.7	1	1	1	0	0.7	0.7	1	IV
B12	0	1	0.3	0.7	0.7	0.7	1	1	0.7	1	0.5	1	1	1	1	V

Figure 2. Diagram of driving power and dependence.

Figure 3. ISM model for barriers.

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