How can countries avoid the next pandemic?

By Shazia Farooqui and Candela Iglesias Chiesa

In the first weeks of the outbreak that today we call COVID-19, it was still thought that the virus could be contained. Many factors played a role so that in the end that was not possible and the virus broke all geographical barriers and reached almost every country in the world.

The spread of COVID-19 reminded us of the downside of our global interconnectedness. In today’s world, people, animals, and food travel across borders in only a couple of hours. Although globalization has many benefits, it can also be a threat to health as certain outbreaks can quickly get out of hand without a proper Global Health response.

Enter the concept of Global Health Security

By ensuring that each country is well-prepared to respond to a disease outbreak, we can protect our neighboring countries and, together, minimize the impacts of health threats globally. This is what Global Health Security (GHS) is about.

I’m sure that you’ve heard this term at least once since the beginning of the COVID-19 pandemic. However, the concept of Global Health Security is not new. GHS activities and tools have enabled us to avoid many epidemics/pandemics in the past (and continue to do so today!).

The WHO defines Global Health Security (GHS) as: “the activities required, both proactive and reactive, to minimize the danger and impact of acute public health events that endanger people’s health across geographical regions and international boundaries”. – WHO, on Health security

1. The 13 Core Capacities of the IHR and the IHR Monitoring and Evaluation Framework

As exemplified by the COVID-19 pandemic, our world faces a number of emergencies that can have drastic impacts on population health. These include infectious disease outbreaks, conflicts, natural disasters, chemical or radio-nuclear spills, food contamination, etc. Such emergencies can be complex, multicausal, and may have severe public health, and also social, economic and political consequences.

These risks, combined with the continued possibility of deliberate or accidental release of pathogens, justify why the global health community is advocating for a whole-of-society, multi-sectoral approach to combat these health threats.

Pandemics, health emergencies and weak health systems not only cost lives but pose some of the greatest risks to the global economy and security. This is why we need global health security; strong and resilient public health systems that can prevent, detect, and respond to infectious disease threats, wherever they occur in the world.

Let’s take the example of an infectious disease outbreak in a country.

How do we know whether this event is serious enough to be considered a ‘public health emergency’ or not?

This is decided by the International Health Regulations (IHR 2005). The IHR are the organizing principles, or the ‘rules of the game’ during a public health emergency. They provide an overarching legal framework that defines countries’ rights and obligations in handling public health events and emergencies that can cross borders.

The IHR require that all 196 countries and WHO member states have the ability to detect, assess, report, and respond to public health risks and emergencies in a timely manner to limit the spread of health risks to neighbouring countries while avoiding unwarranted travel and trade restrictions.

Governments are responsible for implementing IHR at the national level. WHO plays the coordinating role in IHR implementation and, together with its partners, helps countries to build capacities across 13 core areas. (See figure)

But how do countries develop and implement these capacities?

This is done through the IHR monitoring and evaluation framework (IHRMEF), developed by the WHO and Member States. The IHRMEF objectively informs national action plans to strengthen country capacities for public health emergency preparedness and health security.

The IHRMEF has four components:
(i) mandatory annual reporting,
(ii) voluntary after-action reviews,
(iii) simulation exercises and
(iv) voluntary external evaluations, including the joint external evaluation (JEE).

We will discuss each of these components in our global health security series, so stay tuned for upcoming posts!

2. Mandatory annual reporting using the SPAR tool

As we learnt in our previous post, the IHRMEF provides an overview of approaches to review implementation of a country’s core public health capacities under the IHR 2005. These help us understand how well-prepared a country is to respond to a public health emergency.

In today’s post, we discuss one of the four components of the IHRMEF; Mandatory annual reporting using the SPAR tool.

All States Parties are required to have, or develop and maintain, minimum core public health capacities to implement the IHR 2005, and report the status of implementation annually to the World Health Assembly (WHA).

A self-assessment tool called the State Party Self-Assessment Annual Reporting Tool or SPAR, is used for this annual reporting. It can be carried out online, using a web-based platform called the e-SPAR.

The SPAR tool consists of 24 indicators for the 13 IHR capacities needed to detect, assess, notify, report and respond to public health risks . There are 1 to 3 indicators that measure each of these 13 capacities (see figure below). Each indicator is graded into five levels of performance to choose from in the continuum of progress, with Level 1 (red) being the least prepared and Level 5 (green) being the most well-prepared for a given capacity. Countries select the level which best describes their implementation status. The final result is calculated as the average of all the indicators of the given capacity.

How are country’s scored using the SPAR?

There are two components to scoring a country; the indicator level and the capacity level.

The score of each indicator level is classified as a percentage of performance along the Level 1 to 5 scale. For example, if a country selects Level 3 for the indicator C3.1, the indicator level will be expressed as 3/5 × 100 = 60%.

The level of the capacity will be expressed as the average of all indicators. For example, for a country selecting Level 3 for indicator C6.1 and Level 4 for indicator C6.2, indicator level for C6.1 will be expressed as: 3/5 × 100=60% and indicator level for C6.2 will be expressed as:4/5 × 100=80%. So the capacity level for C6 will be (60+80)/2 × 100 = 70%.

Why is SPAR important?

SPAR enables countries to track progress using standardised indicators, and provides a year by year snapshot of country capacities in thirteen technical areas. Consistent and accurate self-assessment contributes to transparency and mutual accountability between States Parties for the collective protection and security from public health threats.

3. Joint External Evaluation (JEE)

How do we know how well prepared for an epidemic or a pandemic a country is? How do we know how well a country can comply with the International Health Regulations (IHR)?

Option A: The SPAR

Countries can use national self assessments like the State Party Self-Assessment Annual Report (SPAR) to understand where they are in their epidemic and pandemic preparedness capacities.

Option B: The JEE

A newer, more qualitative and collaborative assessment tool, called the Joint External Evaluation (JEE), was developed to examine a country’s capacities and establish a baseline assessment. The JEE enabes countries to have a greater understanding of their gaps and weaknesses in health security, so they can focus efforts in these areas.

What is the difference between SPAR and JEE?

While SPAR is mandatory, done annually and has 13 technical areas, the JEE is a voluntary, collaborative and multisectoral process that is recommended to be done every 4-5 years and assesses capacities across 19 technical areas.

Indicators within each of the 19 technical areas are ranked as having ‘No’, ‘Limited’, ‘Developed’, ‘Demonstrated’ or ‘Sustained’ capacity levels, each providing guidance on how to improve upon identified challenges.

The JEE is not an audit of a country’s abilities, but is instead a collaborative effort between the country’s own experts and the external evaluation team. The evaluation does not just examine the human health structure in a country, but encourages collaboration among those responsible for human health, animal health and environmental health.

How does the JEE work?

The entire process takes a few months. This includes time for an initial self-evaluation, preparation and orientation for the external team, the external evaluation and then joint agreement on capacity scoring, strength and priority actions, report writing, and action-planned development. Finally, the results are shared with the international committee in order to gain donor support.

Donors (e.g., member states, public and private partners, and other public health institutions) can support countries in addressing identified JEE gaps, and implementing country-led National Action Plans for Health Security (NAPHS, we’ll talk about those in our next post!)

Countries can prepare for missions by reviewing past JEE reports and action plans posted on the WHO website. In a shift towards transparent reporting and with the realization that many countries face similar challenges, JEE host nations can learn what measures have been recommended and undertaken by countries with similar gaps in their response systems.

4. National Action Plan for Health Security (NAPHS)

Suppose a country has identified gaps in its health systems using tools like the JEE (check out our links below to our previous posts if you don’t know what I’m talking about!). How will the country now plan the implementation of strategies to overcome those gaps?

This is done using the National Action Plan for Health Security (#NAPHS) – a voluntary, multisectoral approach to identify gaps in #healthsecurity and implement activities to address them.

NAPHS is a country owned, multi-year, planning process that can accelerate the implementation of #IHR core capacities, and is based on a #OneHealth for all-hazards, whole-of-government approach. It captures national priorities for health security, brings sectors together, identifies partners and allocates resources for health security #capacitydevelopment.

Developing a NAPHS is a big undertaking for countries, as it requires bringing in experts from different areas of government and getting them to agree on priorities and areas for strategic action. Luckily, there are processes and tools to guide

The first step is to review existing national plans and capacity assessments, carry out stakeholder analysis, SWOT analysis and prioritize technical areas of action. Then there is a need to agree on and prioritize activities within the technical areas chosen and set up a monitoring and evaluation framework

Activities then need to be costed. Once there is clarity on how much activities will cost, available and potential resources can be mapped.

How is the NAPHS funded?

Countries can use NAPHS costing tools developed by various partners, including Centers for Disease Control and Prevention (US CDC), The Food and Agriculture Organization of the United Nations (FAO), World Organization for Animal Health (OIE), Public Health England (PHE) and Resolve to Save Lives. Then funding, either domestic or external (from donors) needs to be found. The NAPHS allows countries to be very specific and evidence based on where the needs are.

How long is a NAPHS?

Strategic NAPHS are usually five-year plans. Some countries develop operational 1-year NAPHS selecting from the 5-year NAPHS priorities areas that they want to tackle first.

Developing a NAPHS enables governments to determine their own health security priorities while encouraging donors and partners to fill in gaps identified by a country’s JEE, in alignment with these country priorities. A NAPHS is critical to ensure national capacities in health #emergency prevention, #preparedness, #response and recovery are planned, built, strengthened and sustained in order to achieve national, regional and global health security and therefore keep the world safe, serve the vulnerable and promote health.

Simulation exercises (SimEx) and real emergency response experience from After Action Reviews (AARs) and Intra-Action Reviews (IARs) help identify bottlenecks in national health systems and can be further used to validate the progress documented in the NAPHS. This allows countries to monitor impact metrics and evaluate progress by testing the functionalities and timeliness of the health system in simulated or real-life.