Over the past decade or more, infectious disease outbreaks have demonstrated that an outbreak in one part of the world can threaten the health of the entire globe. These events have also pointed to the fact that in many countries and regions around the world, public health and health care capacities and capabilities vary. Even in the most developed countries planning and implementation of emergency response plans for large-scale public health emergencies are a significant challenge. In countries where the health care and public health systems struggle to provide services addressing noncommunicable diseases, and the corresponding social and economic costs, responding to infectious disease outbreaks becomes even more of a challenge due to limitations of these systems. Throughout the course of these outbreaks over the past several years, thousands of lives have been lost, the affected communities have suffered severe social and economic challenges, and the cost of responding to these incidents worldwide continues to climb into the billions. Multiple novel and evolving microorganisms have the potential to cause public health emergencies with international scope and since 2003, there have been several outbreaks of emerging and reemerging infectious diseases resulting in significant global health impact (see Box 1-1).
1 The planning committee’s role was limited to planning the workshop. This workshop summary has been prepared by the rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine and should not be construed as reflecting any group consensus.
Ebola virus disease (EVD), formerly called Ebola hemorrhagic fever, was first identified in 1976 in remote villages in Central Africa. The recent outbreak in West Africa—the most widespread to date—began in Guinea in March 2014 and spread primarily to neighboring countries Sierra Leone and Liberia (WHO, 2015d). By the end of July 2015, there were nearly 28,000 confirmed, probable, and suspected EVD cases across those three nations, with the reported number of deaths exceeding 11,000. This total includes 880 confirmed health worker infections and 510 reported health care worker deaths (WHO, 2015c). The most recent global influenza pandemic, H1N1, which occurred between 2009 and 2010, originated in North America and spread throughout the world (Fineberg, 2014). The number of global deaths attributed to the Influenza A virus subtype H1N1 pandemic is estimated to be between approximately 152,000 and 575,000 (CDC, 2012b).
Middle East respiratory syndrome (MERS) is a viral respiratory disease caused by a coronavirus (MERS-CoV). MERS was first reported in the Kingdom of Saudi Arabia in 2012, with epidemiologic investigation confirming the first cluster of cases had originated in Jordan. An outbreak in the Republic of Korea emerged in summer 2015, with 185 confirmed cases and 36 deaths as of July 2015. Globally, there have been nearly 1,600 confirmed MERS-CoV cases and 567 deaths (WHO, 2015f). Another viral respiratory illness caused by a coronavirus is severe acute respiratory syndrome (SARS). In February 2003, a SARS outbreak originated in southern China and eventually spread throughout Asia, Europe, North America, and South America. By July 2003, just a few months after discovery of the
virus, 8,098 probable cases and 774 deaths had been reported to the World Health Organization (WHO) from 29 countries (CDC, 2003).
The 2015 Global Risk Report identified rapid spread of infectious disease as one of the top risks and second in terms of potential impact (NASEM, 2015). The notable infectious disease outbreaks described above are examples of the need for enhanced and sustainable capacity to plan for and respond to global infectious diseases and other public health emergencies, as well as an augmented framework for identifying and effectively responding to the contemporary challenges and realities presented by these emergencies.
The International Health Regulations (IHR), a 2005 agreement among 196 countries designed to improve global health security (WHO, 2005a), was entered into force in June 2007. It is a legally binding framework to promote the global community’s capacity to “better manage its collective defenses to detect disease events and to respond to public health risks and emergencies that can have devastating impacts on human health and economies” (WHO, 2005b). WHO serves as the coordinating body in implementing IHR and assisting countries in building their health systems’ capacities for detecting, assessing, reporting, and responding to public health emergencies.
The IHR agreement codifies the commitment of member states to building their core capacities to the standards set by these regulations. Member states’ surveillance and notification capacities and responsibilities are key stipulations of IHR. States are obligated to notify WHO of events that qualify as potential “public health emergencies of international concern” (PHEIC).2 A PHEIC is declared if an extraordinary event or emergency represents an international public health risk through cross-border spread of disease, and that potentially requires an immediate coordinated international response (i.e., it is serious, unusual, and/or unexpected) (WHO, 2015e). Member states are required to notify WHO of any incidence of smallpox, wild-type poliovirus poliomyelitis, new-subtype human influenza, or SARS (WHO, 2015a). Other illnesses or events are potentially notifiable (including EVD, yellow fever, and cholera) based on a decision support algorithm (CDC, 2015b). Since the inception of IHR, WHO has declared three PHEICs: the influenza A virus subtype H1N1 outbreak in 2009, the
2 As designated by the IHR emergency committee, which provides technical assistance to the WHO Director-General.
outbreak of wild-type poliovirus poliomyelitis in 2014, and the most recent EVD outbreak in West Africa in 2014.3
Member states are also required to have additional technical capacities for preparedness, response, dissemination of risk communication, human resources, and laboratory services. Required administrative capacities include national legislation, policy, financing, coordination, and establishment of a National IHR Focal Point within each country to communicate directly with WHO. However, as of 2014, only 64 of the member states had achieved the required core capacities, with the remainder requesting an additional 2-year extension until 2016 (Katz and Dowell, 2015). These statistics are of utmost concern, because they suggest that only about one-third of the world’s health systems are prepared to respond effectively to a public health emergency. At present, there are no enforceable sanctions in place to penalize countries for noncompliance with the IHR agreement past the deadline, which has already been extended several times.
Lessons learned from the 2003 SARS outbreak helped to shape IHR. Critical weaknesses were exposed in both the capacity of national health systems to respond to public health emergencies and the global capacity to effectively coordinate on an international scale. For example, the first cases of SARS were not detected or reported in a timely manner to WHO, and during the interim months before WHO assistance was requested there was already international spread of the disease. Although the outbreak was eventually contained with limited international public health impact (primarily due to its relatively low transmission rate), it is estimated to have cost the global economy $40 billion (Sidorenko and McKibbin, 2009) and up to $18 billion separately in terms of international trade and travel (Hitchcock et al., 2007). Since the implementation of IHR in 2007, the H1N1 and EVD outbreaks have further revealed gaps and fragilities in national and international-level response capabilities, as well as in the IHR mechanism itself, and underscored the importance of prioritizing health systems strengthening to comply with IHR standards.
A retrospective analysis of the 2009 H1N1 pandemic, which was the first activation of IHR, described how the response to the outbreak exposed: “vulnerabilities in global, national, and local public health capacities; limitations of scientific knowledge; difficulties in decision making under conditions of uncertainty; complexities in international cooperation; and challenges in communication among experts, policymakers, and the public” (Fineberg, 2014). The 2014 EVD outbreak in West Africa has been similarly instructive; a WHO report summarizing lessons learned asserted that a country with a weak health system and limited public health infrastructure is unable to withstand a “sudden shock” like an infectious
3 The MERS-CoV outbreak has not officially been declared a PHEIC by WHO.
disease outbreak. In addition to the health impact of the epidemic itself, its consequences can escalate rapidly into a social, economic, and humanitarian crisis that affects not only the country, but its neighbors and the entire global community. Much of the economic costs of outbreaks arise not from direct effects, but from public anxieties because of misinformation about the spread or lack of a clear leadership response (NASEM, 2015).
Since the 2014 Ebola outbreak many public- and private-sector leaders have seen a need for improved management of global public health emergencies. The effects of the Ebola epidemic go well beyond the three hardest-hit countries and beyond the health sector. Education, child protection, commerce, transportation, and human rights have all suffered. The consequences and lethality of Ebola have increased interest in coordinated global response to infectious threats, many of which could disrupt global health and commerce far more than the recent outbreak.
With encouragement and input from the World Bank; WHO; and the governments of the United Kingdom, the United States, and West African countries; and support from various international and national organizations (Ford, Gates, Moore, Paul G. Allen Family, and Rockefeller Foundations; Dr. Ming Wai Lau; the U.S. Agency for International Development; and the Wellcome Trust), the U.S. National Academy of Medicine agreed to manage an international, independent, evidence-based, authoritative, multistakeholder expert Commission4 on improving international management and response to outbreaks. As part of this effort, the Institute of Medicine convened four workshops in the summer of 2015 to inform the Commission report. These workshops examined questions of governance for global health, pandemic financing, resilient health systems, and research and development of medical products. Each workshop gathered diverse perspectives on a range of policies, operations, and options for collaboration to improve the global health system. A published summary from each of the workshops has been independently written and reviewed and their release will be coordinated.5
4 For more information on the Commission, see http://nam.edu/initiatives/global-health-risk-framework (accessed October 20, 2015).
5 Summaries from the other three workshops can be found at http://iom.nationalacademies.org/reports/2016/GHRF-Governance; http://iom.nationalacademies.org/reports/2016/GHRF-Finance; http://iom.nationalacademies.org/reports/2016/GHRF-Research-and-Development.
To focus on the characteristics of and optimum approaches to building sustainable and resilient health systems that are responsive to emerging infectious disease threats and other public health emergencies, the Board on Health Sciences Policy within the Institute of Medicine of the National Academies of Sciences, Engineering, and Medicine convened Global Health Risk Framework: A Workshop on Resilient and Sustainable Health Systems to Respond to Global Infectious Disease Outbreaks, held August 5-7, 2015 in Accra, Ghana. This document is a summary of the presentations and discussions that took place at the workshop, and is not meant to be a comprehensive overview of how to best build sustainable and resilient health systems. Achieving compliance with the core capacities of IHR and instilling resilience within all sectors in countries to positively impact the health of a population is a multifaceted and very complex goal. Due to limitations of participants’ availability and the timing of this workshop, this summary captures suggestions and ideas from individual speakers and participants on how to accomplish these goals, but they may not be complete or all encompassing. For workshop objectives, see Box 1-2.6
Two fundamental principles underpin strong health systems: resilience and sustainability. Michael Myers, Managing Director, The Rockefeller Foundation, introduced the concept of resilience in health systems by defining it as the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises, thus maintaining core functions when a crisis hits (see Box 1-3). Resilient health systems are continually informed by lessons learned during a crisis and are able to reorganize as needed; they protect human life and produce good health outcomes for all during a crisis, as well as in its aftermath; and they deliver everyday benefits and generate positive health outcomes. Kumanan Rasanathan, Senior Health Specialist, UNICEF, elaborated that resilience is not useful for its own sake; rather, it is useful because it allows for more effective delivery of health care to patients and is flexible enough to respond to unexpected health threats.
Sustainability is the second essential principle of a strong health system, Myers said. Health systems are sustainable when their capacity for day-today care delivery is maintained even during periods of increased demand and emergencies, such as an emerging infectious disease outbreak. For systems that lack such sustainability, outbreaks can expose existing gaps, exacerbate problems, and leave behind a weakened and depleted system
that can no longer deliver day-to-day health care to the population. This ability to achieve sustainability and withstand internal threats is a key goal for health security for developing countries, while developed countries are often more concerned with securing against external threats. As some participants argued, having different preparedness goals (i.e., internal threats versus external threats) makes it difficult to synergize energy and funding to build sustainable systems that are satisfying to all parties. Educating donors on effectively prioritizing allocations to build public health infrastructure can help to address routine threats like dengue fever and maternal mortality—while simultaneously building innate capacity to redirect efforts to an emergency response when needed, said P. Gregg Greenough, Research Director, Harvard Humanitarian Initiative, Harvard School of Public Health.
A health system’s capacity to function comprehensively and effectively on an everyday basis while also being able to respond effectively to—and recover from—public health emergencies is the hallmark of both its resilience and its sustainability, he noted. Further, Ben Adeiza Adinoyi, Africa Zone Health and Care Coordinator, International Federation of Red Cross and Red Crescent Societies added, that having a strong health system is dependent on economic development, and a prerequisite for that is to have strong governance in place. So, while the focus of conversations is often improving fragile or weak health systems in countries to be stronger, he said, any reasonable intervention needs to also look at the governance and leadership challenges that exist in these countries, and not just examine the health facilities in a vacuum.
One important real-world application showing the importance of a health system having the equipment and day-to-day capabilities to function and thrive during an emergency response, is reflected in the comments of Marie Claire T checola, a Guinean nurse and EVD survivor, sharing her perspective from Conakry (see Box 1-4).
This workshop report summarizes the proceedings of discussions in the Ghana workshop, and comprises information presented, concerns raised, priority areas for improvement highlighted, and solutions suggested by the participants during the plenary sessions and the focus area discussions. Chapter 2 covers foundational principles for implementing resilient and sustainable health systems. It includes priorities and principles for leadership and management, such as accountability, ensuring IHR compliance, donor management, and communication. The section on fostering cross-sector engagement spans the topics of integrating public health, mental health, and health care services, and engaging with communities, nongov-
ernmental organizations, civil societies, and the business and private sectors. Chapter 3 presents strategies for strengthening health systems through building countries’ capacities for everyday health care delivery as well as public health infrastructures. Chapter 3 also touches on the needs for robust and resilient supply chains and improved research and clinical guidance. Chapter 4 reports on practical approaches for enhancing information management capacities, including health information and disease surveillance systems. Finally, Chapter 5 addresses the principles and strategies for strengthening outbreak management and emergency response systems.
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