10

Incentives and Preparedness

Milan Brahmbhatt of the World Resources Institute moderated the last session, continuing the preparedness theme developed in the preceding session. Preparedness, he ventured, is the most powerful way to understand pandemics as it involves everything from the human behavior through the multilateral coordination. He encouraged the audience to think about the incentives facing governments and international organizations and how they might be revised.

Richard Gregory of the UK Department for International Development (DFID) opened the panel with a discussion of his agency’s report The Economics of Early Resilience and Response. The report considered whether investments in preparedness and resilience result in a more cost-effective response than traditional humanitarian action. The study modeled three drought scenarios in Bangladesh, Ethiopia, Kenya, Mozambique, and Niger. The first scenario was one of traditional humanitarian response; in the second, an early warning system hastened the humanitarian response; and the third was a prior investment in resilience. Across the different countries, early response cost, on average, 40 percent of the traditional or delayed response cost, and the confidence interval on the estimate was between 7 and 71 percent. Furthermore, the analysis suggested that, although the scenarios were not directly comparable across countries, there was a positive benefit-to-cost ratio of between 2.3:1 and 13.2:1 over 20 years. In short, investing in resilience is highly cost-effective.

The study illustrates the value of early response, Gregory continued, as both cost-effective and frugal. Worries about false signals or hasty response could be minimized in light of its findings, as it would take between two and six early false responses to equal the cost of one delayed action. With this in mind, he encouraged the audience to consider investments in resilience as a high-priority means to humanitarian response. He then mentioned a similar DFID study looking at the agency’s actual spending on preparedness that found a return on investment of between 2:1 and 7:1, to say nothing of the response time hastened by 1 week on average. Gregory saw a transferable lesson for the pandemic financing audience: investing in preparedness

allows for a faster and more cost-effective response. He admitted that his group’s research was not on pandemics or pandemic models and encouraged analysis that would allow for a precise estimate of the amount by which investments in resilience save money in response.

He called back to the previous day’s discussion on value for money and suggested that a financing instrument might be a way to link health systems strengthening with the humanitarian response. He suggested using a prevention, detection, and response framework to organize our thinking. At the level of international institutions, the Stocking report (WHO, 2015) and various commissions can identify ways to improve the international architecture for response. Improving health systems at the country level will also be important. Gregory shared his agency’s conclusion that using the IHR too much as a benchmark might be misguided, and that it is better to look at the total health system in a country and think broadly about what pieces need to be improved to support the key work of detection and response. He gave antimicrobial resistance as an example of an area not necessarily articulated in the IHR, but where progress would support broader pandemic preparedness. Attention to the global health workforce, a core group of epidemiologists and health workers who could deploy rapidly, is another important part of preparedness and a priority for the United Kingdom.

Brahmbhatt then introduced David Nabarro, the United Nations (UN) Secretary-General’s Special Envoy on Ebola, whose prerecorded comments were shown to the audience. Nabarro reiterated Gregory’s points about health systems strengthening, asking for more precision in the way we think about health systems. He said that there are certain priority functions of a health system and that these functions need stable, protected funding. A One Health approach could advance global health security, as outbreaks often have a zoonotic component, and understanding the ecosystem in which humans and animals interact could help reduce the risk of another outbreak.

Nabarro also stressed that national governments are the leaders during an outbreak. He praised the outbreak management done in Guinea, Liberia, Mali, and Sierra Leone, and called for more predictable and systematic support to the logistics and technology that underpin these systems. Long-term support can help build community ownership in the health system. Outbreaks, he pointed out, are transmitted by human behavior. When communities have respectful, open relationships with health workers and feel ownership of the system, behavior change and outbreak control become more manageable.

Ultimately, all of society needs to respond to a health crisis. Nabarro argued that the best response is one where the health sector is empowered to be a critical piece of the response but does not see itself as the entire

solution. He felt that the health system should be attentive to surveillance in human and animal health, responsive to rumors, and able to analyze epidemiologic data. Obviously, the ability to treat patients is essential to a health system, he continued, and treatment needs to include the whole population. Having any marginalized group unreached by services is particularly dangerous during an epidemic, as it allows transmission to persist. Getting to zero cases during an epidemic requires immense organization and discipline, he concluded.

Nabarro reiterated the previous day’s point that only 64 countries report basic IHR compliance. He talked about the challenge of meeting the IHR requirements without standardized methods of data collection and data sharing enabled by interoperable information systems. He stressed that funding for these tools needs to be protected and predictable.

Nabarro observed that outbreaks are disruptive to people’s lives and to economies, driving a natural instinct to secrecy in the early stages. Outbreaks also require changes to the way people live. Ebola, for example, changed the way people bury their dead. Beliefs and traditions are not easy to change, and he described the futility of thinking they could be changed by government or international decree. Outbreaks ask for meaningful behavior change from people, and he asked that we use incentives to reflect that. He saw meeting the basic needs of households under surveillance as a suitable incentive, providing them with mosquito nets, hygiene kits, help getting to the fields, and boreholes to ensure a safe water source when under quarantine. There are also incentives to comply with response. For example, the Sierra Leonean president introduced combined burial teams to employ funeral home and mortuary workers who had been harmed by the new burial practices, reducing their financial incentive to continue with illegal burials.

Nabarro emphasized that coercion and force are not effective in outbreak management, and that the best strategy is to keep the responders and the community on the same side, citing the Sierra Leonean House of Hope as an example of an innovative and sensitive way to quarantine possible cases. People in House of Hope had access to the outside world, talked on the phone, and, even though they were kept separate, were still part of their communities. He praised these kinds of solutions that go far toward demystifying the outbreak and involving the community.

Then the discussion shifted to George Gao of the Chinese Center for Disease Control and Prevention (China CDC) who drew on his country’s experience with severe acute respiratory syndrome (SARS) in the early 2000s. He agreed with Nabarro’s point about the centrality of the local government to outbreak response; Gao saw the capacity of the local government to lead during an emergency as of the utmost importance. The Chinese system has government agencies such as China CDC divided into

provincial and subprovincial levels, all the way down to the township level. He saw this organizational system as helpful and as influencing his agency’s contribution to Ebola response. He said that, if foreign responders had better relationships with local governments, the response might have been more efficient, and that steps could be taken to build that trust now.

When China sent a team to Sierra Leone for Ebola response, they sent two groups: a diagnostic team and a treatment and quarantine team. He had the impression that the region would be better served by investing in the local CDC workers and providing them with master’s- or doctoral-level training in their fields.

Gao also mentioned the problems he had seen on the ground relating to clinical trials and the development of vaccines and diagnostics, cautioning that ethical concerns should not hold back such valuable research in the future.

Hans Troedsson of WHO was the last speaker in the panel. He opened by acknowledging that the audience already seemed sufficiently taken with the idea of investing in resilient health systems. He was grateful for that, describing a functional health system as the cornerstone for any effective emergency response. At the same time, he cautioned against seeing health systems as a magic bullet in pandemic prevention; there are additional challenges beyond health systems building, including designing health delivery and public health systems to complement each other. In his own experience, clinicians and public health workers tend not to understand how to work together, something that happens across countries. He spoke frankly about the limits of what WHO can do, as ultimately the national health system is the responsibility of the government. While WHO has made supporting health systems one of its main priorities, the organization can only support governments, not replace them.

When describing how to support resilient health systems, Troedsson described the value of investing in basic primary care. He acknowledged that vertical health programs in immunization, malaria, HIV/AIDS, and tuberculosis have been some of public health’s most successful and efficient strategies. But he asked the audience to take less interest in the short-term gains vertical programs offer. Building health systems is not a one-off, he continued, and it is not possible to simply put money in health systems once and consider the matter finished. Progress in building systems will require stable, long-term donor commitments.

Troedsson then acknowledged that we will never live in a world where every country has a functional health system. Fragile states and conflict zones will always be part of the world. He compared health systems to a home fire alarm. Ideally, every house should be fireproof, but realistically there will always be houses that are not secured against fire. For those

houses, everyone has to invest in a fire brigade to keep fires from getting out of control or spreading.

When asked about the best strategy to encourage better compliance with the IHR, Troedsson mentioned a recent IHR Review Committee meeting, where they discussed lessons learned relating to Ebola. Participants at that meeting agreed that the IHR is a well-functioning set of rules if they are put in place. Still, only one-third of WHO member states have achieved compliance with the core regulations. Eighty-one countries have asked WHO for an extension on establishing core IHR capabilities, and another 48 have no apparent plan for future compliance. Troedsson cited the failure rate of about 70 percent—almost 10 years after the regulations came into force and by the admittedly low standard of self-assessment—as a huge problem. He acknowledged that WHO was too late to call Ebola a public health emergency of international concern, but emphasized that IHR compliance would be the key enabler of success in the future.

In discussing the IHR, he saw two main categories of countries: those with the technical and financial resources to establish the core capacities and those that lack the money and technical capacity to do the same. He encouraged the use of political pressure on the advanced economies to support capacity development in the rest of the world. He also saw problems with the IHR monitoring system based totally on self-assessment and thought that it might be good to introduce an independent assessment.

Troedsson concluded his remarks by commenting on the devastating financial impact of even a suspected outbreak. Forty countries put travel and trade restrictions against Guinea, Liberia, and Sierra Leone at the peak of the Ebola outbreak, in direct contradiction to the IHR-recommended action. This complicated response work, making it difficult to get food and volunteers to the affected communities. Trade can suffer when a country properly reports an outbreak as stipulated in the IHR. He shared an example from Bangladesh, a cholera-endemic country, where an official at the ministry of health reported a new cholera strain in the early 1990s. Immediately, Gulf countries stopped importing seafood from Bangladesh, to the Bangladeshi economy’s tremendous detriment. Something similar happened in China when milk products were found contaminated with melamine. Troedsson was the WHO representative at the time; he encouraged the Chinese ministry of health to openness and appreciated the government’s transparency. But then other countries quickly stopped importing food from China, in effect punishing the country for observing the food safety component of the IHR. Nevertheless, Troedsson had low enthusiasm for the Stocking commission’s suggestion that retaliatory action against the IHR be tried at World Trade Organization (WTO) hearings. He saw this solution as impractical; the emergency would be over years before WTO could act.

In the open discussion, panelists were asked how to know when a coun-

try is sufficiently well prepared. Gao observed that it is difficult to know in real time, but that hindsight gives some insight. Gregory responded that, since most developing countries are so far from being prepared, it seems unlikely the mark could be passed anytime soon. Asked for his perspective as a representative of a donor agency on what kinds of incentives could encourage compliance with the IHR, Gregory expressed hope that the Global Health Risk Framework Commission would consider that exact question. He recognized that, in some countries, IHR compliance is simply not a priority and suggested that, in these countries, working in mutually beneficial partnerships may be the best answer. Troedsson pointed out that it is not reasonable to think every Pacific Islands country would have sophisticated central laboratories, but that much progress could be made by enabling laboratory sharing and collaboration. Gregory added that winning over ministers of finance to the cause of health systems strengthening could also induce much progress on IHR compliance.

Egerton-Warburton observed that, during an emergency, it is not surprising that countries succumb to pressure and ignore the rules to which they have agreed. He thought that such pressures could create a kind of incentive for preparedness. Troedsson agreed, stating that the final action always rests with politicians, not public health or even finance professionals.

Tore Godal observed that standard protocols for testing and ethical review in emergencies might have shortened the Ebola epidemic by about a month. Completing clinical trials before the emergency might have shortened the outbreak by 2 months, altering the trajectory of the last months of the outbreak. He asked that the audience think through how to shorten outbreaks and make trials move more quickly during an emergency.

Prashant Yadav then gave brief closing remarks, thanking the participants and the National Academies of Sciences, Engineering, and Medicine staff. He introduced Ceci Mundaca-Shah, who discussed the Global Health Risk Framework Commission’s schedule for the summer and its plan to release the report around the end of the year. She invited any interested participants to communicate their ideas on the topic directly to her and her staff. The meeting then adjourned.

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