3
Strengthening Public Health as the Foundation of the Health System and First Line of Defense

National public health systems are essential components of resilient health systems and the first line of defense against the threat of pandemic disease. Robust public health capabilities and infrastructure at a national level are thus the foundation of a global health risk framework. We acknowledge that public health cannot be considered in isolation.

Public health objectives can only be achieved within a highly-functioning and resilient health care system with effective primary care delivery (WHO, 2008b). Indeed, some would argue that public health and primary care are so interdependent and interlinked that talking about them as separate functions is counter-productive. Others would argue in favor of the distinction, because (a) primary care, as part of the health care system, is fundamentally patient-centered, whereas public health is focused on population health; and (b) some public health investments (e.g., laboratories, epidemiologists, health educators, etc.) are quite distinct from those of primary care and are often neglected. Whichever view one takes, both sets of capabilities and infrastructure are necessary to prepare and respond to the threat of infectious diseases. A primary health care system without the support of strong public health capabilities will lack the ability to monitor disease patterns and be unable to plan and mobilize the scale of response required to contain an outbreak. A public health system without strong primary care capabilities will lack both the “radar screen” to pick up the initial cases of an outbreak and the delivery system to execute an effective response strategy. In the context of countering the threat of infectious diseases, public health and primary care serve the same ultimate objective—improving the health security of individuals. Public health approaches this challenge from the macro level by looking at the health security of the population, cascading from the national level down to the community level. Primary care approaches the challenge from the perspective of providing clinical care to individual patients at the local community level.

In this chapter, we will focus on public health systems with the recognition that even countries with highly developed economies and sophisticated health systems have failed to invest in the infrastructure and capabilities necessary to provide essential public health services. Investment in public health is often hard to justify against other priorities, including other health priorities, because the achievements of good public health often take the form of crises averted and are therefore invisible. It takes a disaster like the recent Ebola outbreak to demonstrate the critical importance of this often unsung component of the health system.

Public health capacities at regional and international levels are also important, but national capacities are the foundation of an effective global health risk framework. Regional and global capabilities cannot compensate for deficiencies at the national or local level. Systemic deficiencies in national public health systems, especially the lack of functional disease surveillance and response systems, were key contributors to the length and severity of the Ebola outbreaks in Guinea, Liberia, and Sierra Leone (Kieny et al., 2014). And this is not a problem unique to low-income nations. Recent outbreaks of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) demonstrated that even advanced economies are often unprepared to deliver an effective and timely response to public health emergencies.

Every national government must therefore take responsibility for building an effective public health system and be prepared to be held accountable, both by its own people and, given the externalities, by the international community. Indeed, the importance of national core capacities has been recognized by some individual governments and by the international community, as reflected in the 2005 International Health Regulations (IHR), which establish health security as a global public good (WHO, 2008a). Yet despite widespread agreement on the importance of public health, the global community has failed to deliver. Although countries like Uganda, which has contained several outbreaks of Ebola in the past 10 years, have demonstrated that even relatively poor countries can create effective public health systems, most countries fail against IHR according to even their own self-assessments (WHO, 2015c). Independent, objective assessments would undoubtedly paint an even darker picture.

The Commission believes it is imperative to turn fine words into action. Deficiencies in public health systems need to be identified and resolved. National governments must commit to rapid reinforcement of their public health core capacities. Public health should be treated as an integral part of national security—part of a government’s fundamental duty to protect its own people. To force the pace and ensure accountability, we need (1) clarity on the core capacities required and definition of clear benchmarks; (2) objective, independent, and transparent assessment of a country’s performance against these benchmarks to identify gaps; (3) clear national plans to achieve and sustain these benchmarks, including resourcing; (4) mobilization of resources at a national level, as well as through the international community to fill gaps and sustain benchmark core capacities; and (5) strategies to support minimum standards in fragile and failed states.

DESPITE SOME IMPROVEMENTS, MANY COUNTRIES HAVE FAILED TO BUILD THE NECESSARY PUBLIC HEALTH CAPACITIES

The importance of building strong public health systems was globally recognized following the SARS outbreak in 2002–2003 (GAO, 2004) and the emergence of avian influenza H5N1 in 2003–2004 (FAO and OIE, 2008). These outbreaks exposed weaknesses in detection, reporting, and response similar to deficiencies revealed by the Ebola outbreak. In response, the World Health Organization (WHO) member states agreed to implement the 2005 revisions of the IHR, committing to develop core capacities for detection, assessment, notification, and reporting of events to respond to public health risks and emergencies (WHO, 2008a) (see Table 3-1). This binding agreement also emphasizes the importance of containing emergencies locally.

One of the changes made to the original IHR when they were renewed in 2005 was the addition of a decision instrument to help national authorities determine whether a Public Health Emergency of International Concern (PHEIC) should be reported to WHO. The new instrument replaced a fixed list of specific diseases to report that failed to account for new or unknown threats. Since 2005, WHO has declared a PHEIC three times: the first in 2009 for the H1N1 pandemic; the other two in 2014 for polio and Ebola. H1N1 marked the first time the IHR (2005) were put to the test—and, once again, fragilities in national- and international-level response capacities were exposed, leading to doubts about the IHR mechanism itself.

To address concerns arising from the H1N1 response, WHO’s Executive Board resolved in January 2010 to constitute a Review Committee with three key objectives (WHO, 2010):

1. assess the functioning of the IHR;
2. assess the ongoing global response to H1N1 (including the role of WHO); and
3. identify lessons learned to strengthen preparedness and response to future pandemics and public health emergencies.

The Review Committee, chaired by Harvey Fineberg (then president of the Institute of Medicine [IOM]), submitted its report to WHO in 2011, putting forth 3 overarching conclusions and 15 recommendations (WHO, 2011b). The report observed that core national and local capacities as required in the IHR were not operational in more than half the affected countries, with many lacking the ability to detect, assess, and report potential health threats. It also noted the lack of pathways for countries to ensure timely implementation of the requirements of the IHR.

In order to accelerate the implementation of core capacities introduced in the IHR, WHO developed a guide to support countries in assessment and planning.

TABLE 3-1 IHR Core Capacities and Components

NOTE: IHR = International Health Regulations; NFP = national focal point.

SOURCE: Adapted from WHO, 2015b.

WHO described in this document a range of activities to advocate for IHR implementation, mobilize resources, and monitor implementation plans (WHO, 2013). According to self-assessments by member countries for the years 2013 and 2014 (see Table 3-1 in Annex 3-1), overall improvement over the previous year was limited under several indicators. These assessments also provide further insight into the overall lack of health system capacity, especially in terms of preparedness, human resource capacity, and at points of entry (which includes ports, airports, and ground crossings), with countries in the African region reporting the lowest compliance. Despite some progress, 67 percent of countries self-assessed themselves as not being fully compliant with the IHR (WHO, 2015c).

ROBUST PUBLIC HEALTH CAPACITIES ARE ACHIEVABLE IN THE CONTEXT OF BUILDING AND SUSTAINING STRONG HEALTH SYSTEMS

Before the current West African Ebola outbreak, Uganda was the site of the largest Ebola outbreak in history, with

TABLE 3-2 Ebola Outbreaks in Uganda

SOURCE: Aceng, 2015.

425 reported cases in 2000 (CDC, 2001). Yet the outcome of this outbreak was distinctly more positive, because Uganda had in place an operational national health policy and strategic plan, an essential health services package that included disease surveillance and control, and a decentralized health delivery system (Mbonye et al., 2014). After 2000, Uganda’s leadership realized that, despite the successful containment of the outbreak, a focus on strengthening surveillance and response capacities at each level of the national system would greatly improve the country’s ability to respond to future threats (Aceng, 2015). Uganda has since suffered four additional Ebola outbreaks (CDC, 2014b), as well as one outbreak of Marburg hemorrhagic fever. However, due to its new approach, Uganda was able to markedly improve its detection and response to these public health emergencies (see Table 3-2).

The success of the Ugandan experience is founded in a deep political commitment to strengthen core capacities despite limited resources. The key elements of the strategy implemented in Uganda are described in Annex 3-2.

To build strong public health capacities that will allow detection, reporting, and response to infectious disease threats, countries should focus on revising public health law frameworks, strengthening public health infrastructure; building partnerships; using research evidence to inform program and policy decisions; engaging and improving communication with communities; and establishing a public health emergency operations center (PHEOC) (see Box 3-1).

An alternative, but essentially equivalent, blueprint for reinforcing public health capacities is embodied in the 11 “action packages” set forth in the Global Health Security Agenda (GHSA).¹ This multi-national initiative was launched in 2014, linking several member states, international organizations, and civil society together to prioritize health security activities and help countries to achieve core capacities of the IHR. The GHSA seeks to achieve coordinated action and undertake specific, measurable steps to prevent, detect, and respond quickly to emerging infectious diseases. To facilitate this goal, the 11 action packages provide guidance in areas ranging from prevention to detection to response (see Table 3-3). These packages include baseline assessments, planning activities, and monitoring and evaluation activities that break down the broad issues of global health security into more discrete and attainable goals. As of April 2015, 44 countries had signed on to at least 1 of the 11 action packages with a 5-year target goal, either committing themselves to meet core capacity criteria or assisting another country in need (IOM, 2015). For each action package, there are designated lead and contributing countries that will work together (Katz et al., 2015).

In addition to the country commitments for action packages, a peer assessment initiative began in 2015, with five countries, including Uganda, acting as pilots to measure their progress against each action package.² This process is separate from the IHR assessment, which is carried out by a country individually or in collaboration with a WHO regional office. Although the IHR assessment is a required part of the regulations, there is no system to hold countries accountable, and no penalty for abstaining.

In addition to the five countries that participated in 2015, several have committed to the GHSA assessment process for 2016. Important lessons can be learned from this initiative and the experience gathered from its pilot assessments. For instance, unlike the IHR, the GHSA addresses the importance of having a functional national vaccine delivery system that can be quickly adapted to new disease threats. Action package “Prevent 4” (see Table 3-3) sets a 5-year target of 90 percent coverage of

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¹ For more information, see https://ghsagenda.org (accessed April 1, 2016).

² For more information on the pilots, see http://www.cdc.gov/globalhealth/security (accessed April 1, 2016).

a country’s 15-month-old population with at least 1 dose of measles vaccine (CDC, 2014a). This target was chosen because measles vaccination serves as a proxy indicator for the overall status of coverage for vaccine preventable diseases. A system to deliver vaccines nationwide safely and effectively is an essential component of an outbreak response plan.

Revising Public Health Law/Policy Frameworks³

Although there are many technical and resourcing challenges in building stronger public health systems, in many countries the fundamental impediments revolve around political commitment and governance. Government leaders need to recognize the importance of the overall health system, and public health in particular, to the nation’s human and economic security, and to translate this recognition into budget priorities and concrete plans. Sustained political commitment at the highest levels is essential to devise policies and pass legislation to facilitate the implementation of core capacities, including establishment of national focal points (NFPs), development of laboratory networks and surveillance systems, and provision of adequate financial resources.

Failures of governance, most notably the flourishing of corruption, can be fatal to such efforts, diverting resources and distorting priorities. Of course, corruption and governance weaknesses are a problem for not only public health, but also every aspect of public services. Yet, given the level of governmental commitment required to build resilient health systems with adequate public health capabilities and infrastructure, this arena seems particularly vulnerable to such failures. Addressing the challenge of corruption is beyond the mandate of this Commission, but we recognize the reality of the problem. Civil society organizations, both local and international, as well as the international community, have critical roles to play in holding governments accountable, pressing for improvements in governance, and eradicating corruption.

Strengthening Public Health Infrastructure and Capabilities

Outbreaks cannot be effectively contained if they are not detected promptly. National public health systems must have the capacity to identify an outbreak and establish an alert system to trigger response and, if needed, seek support from regional and global levels. Countries should work to develop real-time detection and response systems, prioritizing elements that reinforce prevention, provide early detection, and enable effective response. Plans to reinforce public health infrastructure and capabilities will need to combine tactical actions delivering short-term improvements with more strategic initiatives to build capacity over the longer term.

Public Health Workforce

Without a skilled, motivated, and well-supported health workforce, no health system can achieve its goals. Yet the world faces a global health workforce crisis—characterized by widespread shortages of skilled personnel, uneven distribution of skills, and, in many situations, poor working conditions (Campbell et al., 2013; WHO, 2006). Many countries lack relevant skills in a range of disciplines essential to public health, including epidemiology, biological and health sciences, veterinary

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³ For the purposes of this discussion, we use the framework set out in Box 3-1.

TABLE 3-3 Global Health Security Agenda Action Packages

SOURCE: Adapted from Standley et al., 2015.

science, psychology, anthropology, and biostatistics. Outbreak planning requires skills outside the medical arena, such as logistics, security, and communications. Building workforce capacity to sustain an effective and responsive public health system is one of the most profound health challenges for many countries. Therefore, countries should commit to developing and implementing a workforce-strengthening strategy and plan that includes training programs for public and veterinary health professionals. Countries should also expand existing initiatives, such as the U.S. Centers for Disease Control and Prevention’s (CDC’s) Field Epidemiology Training Programs (FETPs), which are already being implemented in several countries. Public health workforce strengthening should occur at the community, district, and other subnational levels and through the establishment of national networks to share critical resources and knowledge across public, private, and nonprofit sectors. Countries should also strive to link with regional and global networks to share resources and best practices, participate in training exercises, and collaborate on research studies.

Disease Surveillance and Information Systems

Effective surveillance is critical to containing infectious disease outbreaks. Disease surveillance and health information systems should be developed with the long-term vision of creating nationwide, interoperable, and interconnected platforms that are capable of collecting, aggregating, and analyzing information at every level of the health system (community, district, other subnational, and national levels). Such systems should be able to support both indicator-based (syndromic) surveillance and event-based surveillance. Increased access to new information technology has increased surveillance capacity even in countries with limited resources and should be fully exploited (IOM, 2007). Electronic surveillance tools should be implemented and standardized across the country to transmit information to a central hub that can be accessed in real-time by surveillance staff at every level. For instance, the common use of mobile phones has allowed early detection and response to outbreaks in remote areas (Rosewell et al., 2013).

Surveillance data should be collected in a way that allows integration with data coming from other health and non-health sources, which facilitates the decision-making process by confirming or providing more detail on a specific event. Therefore, countries should avoid the creation of parallel systems, instead seeking to ensure interoperability between existing and new systems. Continuous training is essential, and training guidelines and materials should be updated regularly based on changing needs and priorities.

Strengthening disease surveillance systems would allow countries to comply with IHR requirements and report the occurrence of a PHEIC within 24 hours of receiving indicatory information. Country surveillance guidelines should include procedures and reporting templates to comply with these obligations.

Laboratory Capacity

An effective nationwide laboratory network is another key component of a highly-functioning public health system. Such a network needs to be able to systematically identify, collect, and transport specimens to labo-

ratories with adequate equipment and personnel to carry out reliable testing. Diagnostic capacity should be developed for at least a core list of pathogens (based on the country’s major public health risks). A tiered network should be integrated with the disease surveillance system at every level of the health care system to ensure that information reaches decision makers quickly. Collaboration and communication between human and animal laboratory systems is also vital.

Technological innovation promises more cost-effective and rapid diagnostics. However, it also requires trained biomedical engineers—a scarce resource that is critical to the functioning and integrity of a high-quality laboratory network. Development partners, who provide training, offer technical support for accreditation processes, and aid in the acquisition and maintenance of laboratory equipment, have been essential in resource-limited countries. Community involvement has been equally important in disease surveillance and transportation of laboratory sample efforts, as shown by the experience in Uganda (see Annex 3-2).

Countries should ensure that adequate diagnostic capacity is available either within the country (within the public or private sector), or via a collaboration mechanism established at the regional or global level. To facilitate outbreak response, a catalog of laboratory resources should be developed and made available across the health sector and other sectors involved. Progress at this level will require, as mentioned earlier, the development of national plans for diagnostic approaches that include protocols to handle specimens and apply diagnostic tests. Evaluation against predetermined performance targets is key to monitoring progress and guiding improvement.

Building Partnerships

Government public health agencies are the cornerstones of the public health system, but they cannot work in isolation. To deliver an adequate response during outbreaks, they need to build and maintain partnerships with other public, private, and nonprofit sectors and work closely with communities and community-based organizations.

Within the Health Sector

Countries should make the most of available resources by analyzing the strengths, needs, and challenges of existing systems and avoiding creation of parallel structures. There are already too many examples of vertical interventions in health systems that fail to strengthen the system as a whole (Atun et al., 2008). Effective integration of health care delivery and public health is essential, because outbreaks are typically first detected through primary health care, and because the health care delivery system is critical to executing a response strategy. Such integration must include both public and private health care delivery systems, which play a large role in many countries, because the first (or “index”) case in a potential epidemic could be seen first in either system, or could move between them. For example, the first human cases of H5N1 in Laos (Puthavathana et al., 2009) and MERS in Thailand were seen by private hospitals (Schnirring, 2015). Similarly, the first cases of H1NI in Ghana and Ebola in Nigeria were discovered by private clinics (Freeman, 2014).

It is also important that countries move toward institutionalization of a One Health approach, which integrates veterinary and agriculture practitioners with the public health system (Coker et al., 2011). Globally, a One Health approach has become well established, with the creation of the Global Early Warning System, a platform developed by the World Organisation for Animal Health (OIE), WHO, and the Food and Agriculture Organization of the United Nations (UN) to improve early warning on animal diseases and zoonoses worldwide.⁴ The One Health approach is also an explicit component of the GHSA, embedded, for example, in the action packages on zoonotic diseases and laboratory networks.

Across Sectors

Effective response to a potential pandemic requires deployment of a broad range of skills and assets beyond the health arena. Governments should therefore engage with key players in non-health sectors, such as private companies and civil society organizations, to establish clear communication and coordination at the national, subnational, and district levels. It is key to establish these mechanisms before the emergence of a health crisis.

Working with Development Partners

National governments must ensure that their partnerships with international development partners focus on national capacity building that prioritizes country

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⁴ See http://www.who.int/zoonoses/outbreaks/glews/en (accessed April 1, 2016).

ownership and accountability for health systems based on national plans and aspirations. Development partners should, in turn, respect and support countries’ ownership of health plans and priorities. (For more on country relationships with development partners, see the Rwanda case study in Annex 3-3.)

Working at the Regional Level

National governments should also foster regional approaches to complement country-level efforts, as regional strategies have proved to be an efficient way to address limitations in national resources and skills and bring an element of cultural competency and epidemiological familiarity. Regional initiatives also build trust across professional communities, thereby facilitating communication in times of crisis. The Mekong Basin Disease Surveillance Network, which was established in 2000, is an example of regional collaboration among six countries in Southeast Asia. With a semiformal friendship- and trust-based relationship, the network enables cross-border collaboration and, most importantly, “joint outbreak investigation and control” when outbreaks occur along the border (Phommasack et al., 2013).

Regional capacity should also be built through the expansion of efforts such as the CDC’s FETP, the creation of professional registries, the establishment of laboratory networks, regional mutual assistance agreements, and regional preparedness exercises. WHO regional offices have a key role to play at this level, facilitating coordination between regional health players and supporting regional initiatives.

Using Research Evidence to Inform Program and Policy Decisions

Health systems research is a core function of a learning health system that can continuously assess performance and identify responsive solutions. Lack of capacity for health systems research is a major weakness in many low-income countries (Decoster et al., 2012). Each country should have research capacity built into its health system planning and budget. Social sciences research would help public health leaders understand the social, behavioral, and anthropological aspects of disease preparedness and response, such as effective strategies to engage communities in outbreak detection and control and communicate threats and required responses. The recent Ebola outbreak clearly illustrated the importance of robust representative studies on knowledge, attitudes, and practices regarding Ebola to inform policies and development of effective communication strategies (Laverack and Manoncourt, 2015).

Engaging and Communicating with Communities

Epidemics are shaped by a range of factors that include multiple socio-cultural and economic dimensions. Public health practitioners and policy makers cannot succeed in their endeavors to prevent or respond to infectious disease threats without working closely with communities. Considerable “buy in” and support is essential, as little can be achieved if people are unwilling to accept vaccinations or to consume medications. Public health programs requiring collective behavioral change to interrupt the transmission of infectious disease need the active support and involvement of the communities they wish to assist. Indeed, there are many cautionary cases of communities rejecting public health interventions, sometimes in violent ways. The deaths of several health workers and journalists during the outbreak of Ebola in Guinea in September 2014 are a tragic illustration of extreme negative responses to public health interventions.

Public trust and confidence is a precondition for successfully preventing and containing outbreaks and epidemics. Yet trust can be extremely difficult to build where corruption or other governance failures are prevalent. Where health systems are weak and people question the motives underpinning messages promoting healthy behaviors, public trust and confidence in the work of government and international agencies tend to be minimal, fragile, or absent. It is thus vital that time is taken to engage with, and learn from, local people in an open and flexible way. Such long-term, ongoing engagements not only help create the space for healthy social norms to be established, but also enable pathways that facilitate necessary coordination and mobilization in the event of an outbreak. The recent outbreaks of Ebola in Guinea, Liberia, and Sierra Leone illustrate this point. Doubt, fear, and distrust informed many local people’s responses to interventions proposed by governments and international agencies (Dhillon et al., 2015). In some places, this contributed to, and exacerbated, the transmission of the virus (MSF, 2014), while simultaneously reinforcing preexisting distrust in health authorities.

It is also important to acknowledge and celebrate positive outcomes from community engagement. In Uganda,

for example, most outbreaks are detected through community surveillance systems in which influential community leaders are trained to alert village health teams as soon as they detect any unusual occurrences of death (Aceng, 2015). Ultimately, communities played a vital role in disease surveillance and implementation of countermeasures during the Ebola outbreak. Using a bottom-up approach, public health authorities were able to devise ways to influence deep-seated cultural practices and behaviors related to burial rites, caring for the sick, and social gatherings, which were key contributors to the mitigation or containment of the outbreak (Aceng, 2015). Box 3-2 offers guidance on how to engage communities before, during, and after infectious disease outbreaks.

Community-based service providers (of health, education, and security, among others), local government officials, elected members, staff working at local nongovernmental organizations (NGOs), and anthropologists are well placed to liaise with local people. These professionals recognize the need to work with a range of influential people in many roles and understand the importance of developing trusting relationships. They also have many valuable skills, including fluency in the local language, as well as the willingness to talk, listen, and observe to acquire a thorough understanding of the range of perspectives that make up the local culture. Also essential is a willingness to let go of preconceived ideas and recognize that local people may well be able to come

up with novel solutions to contain outbreaks and resolve complex public health issues. Anthropologists are well placed to identify deep sociocultural conditions that may impact the course of the overall epidemic and the response at multiple critical points; they should describe the practical relevance and applicability of their findings to facilitate acceptance and implementation of their recommendations (Abramowitz, 2014).

Effective communication is a critical component of preparedness and response to outbreaks. Preventing and containing infectious disease presents particular challenges because options for interrupting transmission are often limited, and it is crucial that change occurs at speed. Therefore, communications should be approached as a progressive, adaptable process, rather than a monolith of simple messaging.

Public health officials should develop context-specific approaches that recognize the influence of history, culture, and social forces in their population. For more information about the influence of history in the response of the community to containment measures implemented during outbreaks of infectious diseases, see Annex 3-4. Social media offers promising tools to reach different groups with appropriate messaging. However, messaging must be carefully researched and framed for the context and cultural practices of the targeted audience. Simple, standardized messages grounded in a biomedical understanding of contagion can be ineffective if they ignore these factors. In fact, recent experiences in West Africa (Chandler et al., 2015), as well as in past outbreaks of Ebola in Uganda (Hewlett and Hewlett, 2008) show how oversimplified messaging can reinforce rumors and anxieties, discourage active engagement with local social realities, and erode opportunities to identify changes that are appropriate as well as practical and socially effective.

Establishing a Public Health Emergency Operations Center

To ensure effective response to an infectious disease outbreak, countries need a well-resourced PHEOC. In the event of a crisis, the PHEOC will integrate public health services with other parts of the health system and incorporate resources from outside the health sector into an emergency management model to implement the outbreak response plan (WHO, 2015a). The PHEOC will be responsible for coordinating all sectors involved in delivering the response plan, including those beyond the health sector, as well as the training and deployment of emergency workforce resources. To be effective, the PHEOC will need to be well established, with appropriate resources and financing, and to have developed and tested the required coordination mechanisms in advance, preferably through rehearsals. The PHEOC should have direct access to national disease surveillance and laboratory systems and possess infrastructure to enable rapid analysis of information to inform decision making. The PHEOC should also work with development partners and regional and global networks to identify where international support is most needed and coordinate its delivery to affected communities.

NATIONAL GOVERNMENTS’ RESPONSIBILITY TO PROTECT THEIR OWN PEOPLE AND PLAY THEIR PART IN PROTECTING HUMANKIND BY IMPLEMENTING THE INTERNATIONAL HEALTH REGULATIONS

National governments must take the responsibility to prevent, detect, and control infectious diseases outbreaks; to protect their own populations; and to play their part in protecting global health security. This goal can only be achieved in full when countries have built effective public health services, operating as an integral part of resilient health systems and capable of recognizing, reporting, and arresting the spread of infectious diseases. This cannot be achieved overnight. To ensure that national governments are equipped to achieve this goal, the Commission proposes a set of recommendations.

Clear Definition of Core Capacities and Benchmarks

A clear definition of public health core capacities and functioning is needed to enable countries to develop concrete plans and facilitate compliance with the IHR. Establishing benchmarks is also key for conducting robust, objective assessments and identifying gaps, which in turn will allow prioritization of expenditures and enable accountability.

Recommendation B.1: The World Health Organization, in collaboration with member states, should develop an agreed-on, precise definition and benchmarks for national core capabilities and functioning, based on, and implemented through, the International

It should not be necessary to open the IHR to renegotiation to determine new definitions and benchmarks, because these could be developed through informal means, such as by an Annex or through the Director-General’s (DG’s) operational benchmarks for implementing the IHR (Gostin et al., 2015). The need for a clear roadmap that moves away from implementation checklists was also identified by the IHR Review Committee on Second Extensions for Establishing National Public Health Capacities and on IHR Implementation and approved by World Health Assembly (WHA) Resolution 68.5.

Objective, Independent, and Transparent Assessment of Individual Country Performance Will Enable Prioritization and Reinforce Accountability

In 2011, WHO issued a comprehensive IHR Core Capacity Monitoring Framework and accompanying monitoring tool to all member countries to enable them to assess their capacities (WHO, 2011a). This tool contains 13 sections and more than 100 subsets of information. WHO has received detailed self-assessment reports from the member countries since 2011 on an annual basis. During the past 5 years, 98 percent of all states parties have responded to the monitoring questionnaire at least once (WHO, 2016). The monitoring tool has enabled countries to understand the significance of complying with the IHR and has also lent a measure of in-country accountability. There is greater awareness of health security issues and the necessity to build core capacities. Most countries have instituted an NFP and established a communication link between the country and WHO focal points. This in itself is a vast improvement over the pre-2005 IHR period.

Thus, while the IHR have undoubtedly been a valuable legal instrument (WHO, 2011b), the WHO monitoring tool and its subsequent revisions, though developed by experts, do not provide clear guidance for countries on how to prioritize implementation actions. While many have focused on training human resources, building surveillance systems for reporting of outbreaks, establishing reporting and review mechanisms, and creating rapid response teams for containing outbreaks, others have focused on less critical elements—for instance, procuring thermoscans for screening at airports.

The IHR reports submitted by member states have limited credibility, primarily because they are self-assessments. Furthermore, the WHO monitoring tool only allows for binary yes-or-no answers to many questions. For example, under Core Capacity 1 for the category “National Legislation,” many countries would need to revise several laws to be truly “compliant” with IHR requirements. However, for instance, updating a Public Health Act without any changes to other laws, such as the wildlife or environment laws, would allow them to report themselves as compliant. Or, for example, under Core Capacity 2, for “Coordination and NFP Communications,” multisectoral task forces may have been constituted, but their meetings are often irregular and not conducted until after an outbreak has occurred. Likewise, while NFPs have been established, they are often small units lacking infrastructure, trained personnel, and adequate budgets.

Recommendation B.2: The World Health Organization should devise a regular, independent, transparent, and objective assessment mechanism to evaluate country performance against the benchmarks defined in Recommendation B.1, building on current International Health Regulations monitoring tools and Global Health Security Agenda assessment pilots, by the end of 2016.

Proposed Structure of the Assessment

We propose the following structure for the assessment.

The objective assessment should be overseen by an independent panel appointed by the Technical Governing Board of WHO’s Center for Health Emergency Preparedness and Response (CHEPR) and answerable first to the WHO DG and ultimately to the Executive Board and the WHA. (WHO CHEPR is a key element of our recommendations for WHO and discussed at length in the next chapter.) This body will be responsible for defining metrics and developing instruments and tools to measure progress on implementation of core capacities. This panel will build on the IHR current assessment

mechanism and lessons learned from other initiatives, such as the GHSA experience.

Because it will not be possible at the start to conduct assessments of every country simultaneously, the panel should prioritize countries most in need of an external assessment. Countries should also have the ability to request an external assessment. Ultimately, assessments should be conducted on an annual basis, but we recognize that getting to this point will take some time. Peer representatives from both within and outside the region should play a key role in conducting panel reviews. The panel should develop an annual report to present to the WHA (which should also be made public) that should include progress on the implementation of core capacities and indicators that track notification and verification of events, communication, and coordination with NFPs.

The assessment tools should be approved by the WHA and measure performance in two main areas:

1. implementation of core capacities (including national legislation, coordination and NFP communications, surveillance, response, preparedness, risk communication, and laboratory capacity); and
2. early detection, notification, and response to outbreaks.

Discussion of the results of this assessment should include members of the country under assessment in order to ensure agreement on recommendations for support and follow-up.

In designing the details of this assessment mechanism, the panel should draw on the experience of analogous assessment mechanisms from outside the health sector, such as the World Bank’s Doing Business reports, which are detailed assessments of the regulatory and infrastructure environment for establishing a business, or the Financial Action Task Force Mutual Evaluation mechanism, which is a peer-review process focused on the effectiveness of anti–money laundering systems and regulations. In both examples, the assessments are rigorous, objective, and transparent and serve a powerful purpose in galvanizing policy.

We recognize that such assessment processes inevitably generate frictions and disputes about methodology. The Commission is fully aware of the debates (Bialik, 2009) following WHO’s World Health Report 2000 (WHO, 2000). Our objective here is not to create a ranking, nor to assess overall health system performance, but to provide a focused assessment of critical public capacities with the goal of enabling prioritization and accountability. Rigorous, objective, and transparent assessment will help identify weaknesses and illuminate opportunities to improve national prevention, detection, and response systems.

Recommendation B.3: By the end of 2016, all countries should commit to participate in the external assessment process as outlined in Recommendation B.2, including publication of results.

Without appropriate incentives, countries may seek to avoid objective and transparent assessment and thereby continue to neglect their health system capacities and infrastructure. One potential way to encourage participation in the assessment mechanism is to make external funding from the World Bank and/or other partners contingent on participation.

Recommendation B.4: The World Bank, bilateral, and other multilateral donors should declare that funding related to health system strengthening will be conditional upon a country’s participation in the external assessment process.

Another potential mechanism for encouraging countries to meet domestic and international obligations around pandemic preparedness should be for the World Bank and International Monetary Fund (IMF) to include assessments of pandemic preparedness in their country assessments. As discussed in Chapter 2, infectious disease outbreaks represent a substantial threat to countries’ economic prosperity. Appropriately reflecting the risk associated with under-preparedness in assessments of macroeconomic stability would allow economic actors to take such risks into account when making decisions about investments and loans. Access to capital through development banks, capital markets, or foreign direct investment may be adversely affected if countries are known to have underdeveloped pandemic prevention and response capacities. If the IMF routinely included the outcomes of external assessments of national pandemic preparedness in its reviews of countries’ economic and financial situations, countries keen to engage in global financial markets would have to pay heed. Those that chose to avoid external assessment would risk adverse signaling.

Recommendation B.5: The International Monetary Fund should include pandemic preparedness in its economic and policy assessments of individual countries, based on outcomes of the external assessment of national core capacities as outlined in Recommendation B.2.

Primary responsibility for achieving and sustaining public health capacities to the required standard rests with national governments. We therefore call on governments to develop and publish plans by mid-2017 (where plans do not already exist) to achieve benchmark status in the required core capacities by 2020. These plans should be comprehensive and realistic, addressing the challenges of sustainable financing and skills building.

Recommendation B.6: Countries should develop plans to achieve and maintain benchmark core capacities (as defined in Recommendations B.1). These plans should be published by mid-2017, with a target to achieve full compliance with the benchmarks by 2020. These plans should include sustainable resourcing components, including both financing and skills.

Country plans should also be aligned with global initiatives that share similar objectives, such as the Sustainable Development Goals (SDGs) adopted in September 2015 by the UN General Assembly under the title Transforming Our World—The 2030 Agenda for Sustainable Development.⁵ This initiative represents a global compact and movement that will be the vehicle for mobilizing and galvanizing country and global actors for concerted action on national and global issues. The SDGs will be used for holding country leaders accountable and can also act as the entry point for bringing the global health security agenda into the routine work of the UN, including the Security Council.

To assist national governments in developing and implementing plans to build stronger core capacities, WHO should provide technical assistance, ensuring the transfer of best practices.

Recommendation B.7: The World Health Organization (WHO) should provide technical support to countries to fill gaps in their core capacities and achieve benchmark performance. (Technical support will be coordinated through a WHO Center for Health Emergency Preparedness and Response; see Recommendation C.1.)

Financing the Required Improvements in National Public Health Systems

Public health services are an integral part of any health system and a key driver of health system resilience. However, public health is often starved of investment, even relative to other parts of the health system (RWJF, 2013). Why is this?

One reason is a certain level of invisibility of outcomes, as explained earlier in this chapter. Avoiding outbreaks is a negative achievement. Building resilience can be difficult to measure and easy to undervalue. As in the Biblical parable of the house on the sand and the house on the rock, weak foundations are only exposed when the storm hits (Matthew 7:24–27).

Secondly, national resource constraints and competing priorities mean that investment in strong and resilient health systems, which deliver benefits over the long term, often gets crowded out amid clamor for spending in areas where the benefits are more immediately and directly obvious. This problem is particularly acute in the poorest countries, but it is not unique to them. Even rich countries have this challenge. It takes a crisis like Ebola to reveal the enormous social and economic costs of neglecting the fundamental infrastructure and capacities of national health systems.

Thirdly, the prioritization of global aid agendas and financing mechanisms can create challenges in building coherent and resilient health systems. A focus on specific diseases (vertical programs) and other health-related targets, which prevails in much of the international development assistance community, can lead to neglect and fragmentation of the underlying health system (Flessa and Marx, 2016; Oliveira and Russo, 2015). For understandable reasons, many donors take a deliberately narrow focus, channeling their resources and energies toward meeting sharply defined program targets for specific diseases. Such single-minded focus helps deliver short-term results. However, a profusion of narrowly focused initiatives, each pursuing specific program goals

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⁵ SDG3, which is to “ensure healthy lives and promote well-being for all at all ages,” has three specific goals—(3.d) on outbreak preparedness and response, (3.b) on vaccines, research and development and (3.c) on health financing and health workforce recruitment, development and retention. See https://sustainabledevelopment.un.org/post2015/transformingourworld (accessed April 1, 2016).

without much attention to linking the public health and health care delivery systems, can create a kind of “tragedy of the commons,” as Garrett Hardin described in 1968 (Hardin, 1968).

This phenomenon was somewhat evident in West Africa during Ebola. Before the epidemic, and despite neglected and fragile health systems, vertical program funding had enabled gains in specific indicators, such as child and maternal health and immunization. Yet during Ebola, health systems collapsed and those specific gains from vertical programs were reversed, at least in part. Neglecting the foundation makes the gains from other health programs extremely fragile.

Reinforcing health system resilience and preparedness at the level of individual countries will require sustained incremental spending, given the significant gaps in capacities and infrastructure of many countries. Estimating the scale of incremental investment required is challenging, as the available information on each country’s current status is far from perfect, and the costs of upgrading capacities will vary substantially among different countries. Even taking these challenges into account, however, it is obvious that significant investment is needed to strengthen national systems. Currently, only one-third of countries report themselves to be fully compliant with IHR guidelines (WHO, 2015c), and even this may be an overstatement, given that compliance is self-assessed and benchmarks broadly defined.

The most credible estimate of the costs of reinforcing national capacities and infrastructure to achieve IHR compliance comes from a 2012 World Bank report, which concluded that achieving compliance for only low- and middle-income countries would cost between $1.9 and $3.4 billion⁶ per year (World Bank, 2012). This figure includes expenditures on a range of essential functions across both human and animal health sectors.⁷ For human public health systems, these include the costs of strengthening surveillance and diagnostic capacities, as well as upgrading disease control measures. For veterinary health services, the costs of surveillance, biosecurity, diagnostics, and control, as well as culling and resultant compensation, are included, along with the costs of enhancing wildlife surveillance, diagnosis, and disease control.

While the World Bank estimates might be based on imperfect data, there is good reason to believe that they reasonably represent the scale of investment required. A 2009 estimate by the IOM/National Research Council Committee on Achieving Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of Zoonotic Origin concluded that an annual expenditure of $1.34 billion would be needed annually through 2020 to address the pandemic threat of avian influenzas alone (IOM and NRC, 2009). It thus seems reasonable that strengthening national systems to address the broader threat posed by all potential pandemic disease agents will cost even more. Indeed, taking into account the need to upgrade capacities in many higher-income countries—as well as the low- and middle-income countries included in the World Bank analysis—it is likely that the overall investment gap today is nearer the upper end of the World Bank estimates ($3.4 billion). This amount is in addition to other investments recently proposed for health systems strengthening. For example, the Lancet Commission on Investing in Health proposed an incremental investment in health systems strengthening of $17 billion per year to 2035; however, this estimate did not include the resource demands to prepare for new infectious threats, such as pandemic influenza (Jamison et al., 2013).

In considering potential sources of such incremental funding, two key considerations are sustainability and externalities. Health systems resilience should be viewed by all countries as an ongoing requirement, rather than a one-off effort, so the funding approach needs to be sustainable. Furthermore, given that it is the foundation of health security, spending on public health infrastructure and capacities such as surveillance systems and laboratory networks should be seen as a component of national security expenditures, and therefore as an integral part of a government’s fundamental duty to protect its people. A country’s investment in public health capabilities and

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⁶ All monetary figures in U.S. dollars.

⁷ The estimates were developed following a 2-year process of research and expert consultation, involving the collection of budget data from 88 countries. Estimates of required spending were disaggregated by service and disease type in order to produce global estimates of the expenditures needed to meet WHO/OIE standards, and estimates of annual spending were extrapolated to the full set of 139 low- and middle-income countries. The report emphasized a One Health approach, entailing interdisciplinary collaboration among systems focused on human, animal, and environmental health. This approach to pandemic preparedness can be justified on two grounds: first, zoonotic diseases constitute the bulk (more than 60 percent) of emerging infectious diseases; and second, many of the elements of One Health strategies, such as national laboratory networks, would be applicable to any emerging disease threat.

infrastructure also creates positive externalities, because other countries will benefit from the resulting reduction in infectious disease risk (and, conversely, the failure to make such investments creates negative externalities). The presence of such powerful externalities underscores the logic of high-income countries supporting low-income countries in making these investments.

In this context, we suggest the following:

• High-income and upper-middle-income countries must make achievement of the IHR core capacities a central part of the government’s expenditure, most likely funded through general resources or possibly via dedicated taxes.⁸ Civil society will be able to hold governments accountable for devoting sufficient resources to achieving IHR compliance through the mechanism of independent assessment described in Chapter 3. For countries in these income brackets, it also makes sense to establish emergency contingency funds where they do not already exist. Such funds could cover a broader range of potential emergencies than pandemics alone.
• Lower-middle-income and low-income countries should discuss with their multilateral and bilateral partners the appropriate balance of domestic resource mobilization and external support (which might be directed at helping upgrade capacities and infrastructure, contingent on local governments’ commitments to maintain support thereafter). This could be achieved through a range of options, including:
  1. individual country-level negotiations with donor partners around national plans to rectify gaps;
  2. negotiations under the umbrella of existing multi-country initiatives, such as the GHSA and the World Bank–funded Laboratory Network in 18 countries in east, central, and southern Africa;
  3. through the creation of a new fund, with grants and/or loans linked to commitment to ongoing financial support from domestic resources; and
  4. a combination of Options 1 and 2, with the World Bank providing overall coordination to minimize duplication and gaps.

We believe Option 4 provides the optimal blend of flexibility for funding efforts in lower-middle- and low-income countries. This would enable the global community to build on the momentum of initiatives such as the GHSA, leveraging other, more focused health financing vehicles such as Gavi and the Global Fund and drawing on new potential sources of financial support, such as the New Development Bank and the Asian Infrastructure Investment Bank. We believe Option 3, a dedicated fund specifically focused on pandemics, would not be optimal, given that the investment we envisage is so integrally entwined with the reinforcement of the overall health system and overlaps with initiatives to target other health challenges, such as antimicrobial resistance (AMR).

Whatever the initial balance between domestic and donor spending, there should be a plan to reduce reliance on external funding through domestic resource mobilization. Building and sustaining local health system resilience should be seen as a core function of the national government and integral part of the budget. For example, the visible economic growth reported in many African countries should also be reflected in growing health expenditure.

For fragile and failed states, where local governments are not in a position to develop or execute such plans (let alone fund them), there should be a strategy for building and sustaining the most critical public health capacities to the extent possible. This will also be true where governments systematically ignore their responsibilities, pay only lip service to them, or allow implementation to be fatally undermined by corruption. Given that each of these situations has unique characteristics, this report refrains from prescribing a single approach to addressing and resourcing such challenges. However, it is clearly in the interest of global health security to incorporate consideration of infectious disease preparedness and response challenges in determining the UN or broader international strategy toward such situations.

Irrespective of a country’s income level, the health systems investments described here should be guided by:

• a clear definition of the core capacities required (see Recommendation B.1);
• rigorous, objective, and transparent assessment of current performance against these defined capacities (see Recommendation B.2); and

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⁸ For example, the IOM/National Research Council Committee on Achieving Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of Zoonotic Origin suggested a possible tax on the meat trade (IOM and NRC, 2009).

• clear and detailed plans to rectify gaps, including the costs of upgrading core capacities and a model for sustainable funding.

Recommendation B.8: National governments should develop domestic resourcing plans to finance improvement and maintenance of core capacities as set out in the country-specific plans described in Recommendation B.6. For upper- and upper-middle-income countries, these plans should cover all financing requirements. For lower-middle- and low-income countries, these plans should seek to develop a pathway to full domestic resourcing, with a clear timetable for achieving the core capacity benchmarks.

Recommendation B.9: The World Bank should convene other multilateral donors (including the African Development Bank, Asian Development Bank, New Development Bank, United Nations Development Program, and Asian Infrastructure Investment Bank) and development partners by mid-2017 to secure financial support for lower-middle- and low-income countries in delivering the plans outlined in Recommendation B.6.

Recommendation B.10: The United Nations (UN) Secretary General should work with the World Health Organization and other parts of the UN system to develop strategies for sustaining health system capabilities and infrastructure in fragile and failed states and in warzones, to the extent possible.

CLOSING REMARKS

While the public health component of a health system is the first line of defense against the threat of infectious diseases, it has been seriously neglected by even the most advanced economies. Strengthening public health capacities should be a health security priority for governments and the global community. To achieve this, WHO, in coordination with member states, should develop clear standards and benchmarks for national core capacities and functioning and devise a regular, independent, and transparent assessment mechanism to evaluate countries’ compliance.

At the country level, political will is essential to develop and implement plans to achieve and maintain benchmark core capacities. For resource-limited countries and fragile and failed states, the World Bank should develop finance mechanisms in collaboration with other multilaterals and development partners to support these efforts. This funding should be conditional upon a country’s compliance with the external assessment mechanism. WHO should play an important role in providing technical expertise to support countries in the implementation of such plans. Strengthening public health systems will not only prevent a future outbreak from spinning out of control, but also support other critical efforts to combat global health threats, such as AMR.

CHAPTER 3 ANNEX

ANNEX 3-1
TABLE 3-4 Status of Core Capacities by Region for the Years 2013 and 2014

NOTE: AFRO = Regional Office for Africa; AMRO = Regional Office for the Americas; EMRO = World Health Organization (WHO) Eastern Mediterranean; EURO = WHO Europe Regional Office; SEARO = WHO South East Asia Regional Office; WPRO = Western Pacific Regional Office.

SOURCE: Adapted from WHO, 2016.

ANNEX 3-2

Uganda Case Study

Political Commitment: National Legislation and Development Plans

Following the 2000 Ebola outbreak and based on results from an assessment of the vertical surveillance strategy in place at the time, a 5-year strategic plan for the health sector was developed and implemented (MOH, 2000). This assessment indicated that investment and improvement on the existing passive, limited approach to collecting surveillance information and the less-than optimal coordination and communication between the district, regional, and national levels would result in reducing the threat, morbidity, and mortality of epidemics through an early-warning system and quick response (Lukwago et al., 2012; Phalkey et al., 2013). As part of the new strategy, Uganda moved to strengthen WHO’s “Integrated Disease Surveillance and Response Strategy.”

Coordination and Collaboration

The Ugandan system is coordinated by a standing multidisciplinary and multisectoral National Task Force (NTF) that meets monthly to review surveillance data and update preparedness plans; during an outbreak, the NTF meets daily (Aceng, 2015). It is led by the Director General of the Ministry of Health (MOH), and its members are drawn from various fields of expertise, including epidemiology, veterinary medicine, communication, and laboratory science—all from various ministries within the government, the military, the Office of the Prime Minister, research institutions and universities; representatives from WHO and the CDC; and participants from civil society and NGOs such the Uganda Red Cross and Médecins Sans Frontières (Aceng, 2015).

A PHEOC was recently established to assist the NTF and the district task forces (DTFs) created by coordinating emergency capacities through receiving, evaluating, and distributing information collected from

surveillance activities, laboratories, and communication networks (Bourchert et al., 2014). The PHEOC is activated immediately following outbreak detection (Aceng, 2015).

Community Engagement

Social mobilization has been critical to Uganda’s success. Local leaders and various professionals are involved throughout the discussion and are trained on basic principles of identifying certain diseases, such as Ebola (Lamunu et al., 2004). Respect for cultural traditions and understanding of knowledge, attitudes, and beliefs of the affected area shapes the mobilization effort, and the government works closely with the United Nations Children’s Fund and the Uganda Red Cross to engage traditional healers and religious leaders to support social mobilization efforts (Aceng, 2015; Lamunu et al., 2004; Mbonye et al., 2014).

Integrated Disease Surveillance System

The disease surveillance system functions at all country levels: national, sub-national, district, and sub-district. A DTF exists in all 112 districts of the country. Its membership is comprised of political, health, and community leaders and relevant technical advisors, led by the politically elected Chairman of the Local Council (Borchert et al., 2011). There are designated surveillance and laboratory focal persons at the district and regional levels who regularly receive and review surveillance information (Aceng, 2015). Village health teams are responsible for 20–30 households and were established as an integral component of the national strategic plan to improve access to care, social mobilization, governance coordination, and community-based preventive or rehabilitation services (Aceng, 2015; MOH, 2000, 2015).

Information Systems and Use of Technology

Data from all health facilities in the country are shared with providers and health workers through a weekly epidemiological bulletin produced by the MOH Epidemiology and Surveillance Division and Resource Center. A comprehensive short message service (SMS) alert system is established to boost surveillance, with members of the District Rapid Response Teams, the District Surveillance Officer, and the hub coordinator sending texts to the system, which then forwards alerts to all members of the NTF. The SMS reporting system and a specimen tracking system are accessible to the PHEOC through the District Health Information System (DHIS-2), which is used to report national health data and provide real-time monitoring and evaluation through an online platform. Access to the DHIS-2, which is now linked up with the SMS facility data transmission system, allows the PHEOC to be the primary center of communication and the coordination site of response decisions and subsequent implementation by the NTF in an emergency (Bourchert et al., 2014). The use of standardized forms for data collection, as well as a specific individual assigned to data management for each outbreak, allows for coordinated management and dissemination of information to health care workers and the public (Aceng, 2015).

Infrastructure and Laboratory Capacity

Laboratory services are available beginning at the health sub-district level and grow increasingly more complex in scaling up the health system, with approximately 1,700 health facilities providing basic minimum laboratory services (Kiyaga et al., 2013). A biosafety level 3 laboratory at the Uganda Virus Research Institute (UVRI), funded in part by the CDC after a 2007 Ebola outbreak, allows for fast turnaround and identification of samples (Aceng, 2015; Mbonye et al., 2014; MOH, 2000). Samples are concurrently sent to the CDC for testing. The decentralized laboratory network allows for isolation units to be set up when the need arises, allowing for quick control and containment. Upon confirmation, a daily situation report called the “Sitrep” is produced and distributed, and WHO is notified immediately (Aceng, 2015).

As many health facilities have only basic laboratory services, a National Sample and Results Transport Network was established to allow for quick and efficient transport of samples, coordinated by the Central Public Health Laboratory. Funded in part by the Global Fund, the transport network identified 77 hubs throughout the country with enhanced laboratory capacity (Aceng, 2015; Global Fund, 2014; Kiyaga et al., 2013). The hubs act as a coordinating center and serve approximately 20–40 health facilities in a 30–40 km radius around the hub (Kiyaga et al., 2013). Each hub is serviced by a motorbike rider who visits 4–8 hubs on a given day. They reach every facility at least once per week, delivering the previous week’s results and picking up samples (Aceng, 2015; Kiyaga et al., 2013; Mbonye et al., 2014). In emergency situations, riders for each hub are on reserve to pick up

TABLE 3-5 Uganda Strategy Building of Core Capacities

SOURCE: Summary of Aceng, 2015.

samples, and transport them to the postal service, Posta Uganda, for transportation to UVRI. This process in its entirety is designed to take less than 24 hours (Aceng, 2015). SMS alerts are sent to the hub coordinator at each point to notify them of specimen registration, UVRI receipt, and release of results, with data in parallel tracked through DHIS-2 (Aceng, 2015).

Health Workforce Capacity

Currently the country is implementing a comprehensive training in all the 14 Regional Referral Hospitals to build standby Case Management Teams readily available to support respective districts as need arises. These will further serve as the decentralized monitoring and evaluation centers for Integrated Disease Surveillance and Response countrywide. Surveillance efforts are boosted with the CDC’s FETP. This program trains field epidemiologists in investigating any unusual deaths or occurrences, and these field epidemiologists are deployed with surveillance officers to assist with contact tracing (Aceng, 2015).

Community health workers (CHWs), who comprise the village health teams, are trained on standardized clinical and community case definitions, reporting of any unusual events, and surveillance activities to enable early reporting from the community level to their respective attachment health facilities (Aceng, 2015; Lamunu et al., 2004; MOH, 2015).

Communication and Education

CHWs serve as a valuable link between the community and the health sector. For example, in cases where the patient is kept in isolation, CHWs brief families on a daily basis and contact burial teams to bury the dead with dignity while maintaining adherence to outbreak control practices (Aceng, 2015). The media is well utilized with daily radio discussions, “aggressive” documentary screenings of previous outbreaks, and widely circulated posters and dissemination (Aceng, 2015; Lamunu et al., 2004).

Summary

In summary, taking the lessons learned from the 2000 Ebola outbreak, Uganda started a process of building public health core capacities that strengthened its surveillance and response systems, which significantly improved the outcome of several subsequent Ebola outbreaks. As shown in Table 3-5, these key elements implemented aligned very well with the core capacities included in the legally binding IHR.

ANNEX 3-3

Rwanda Case Study

Where needed, governments should work with development partners to strengthen health systems capacity with an approach that focuses on country ownership and accountability. Rethinking the current approach to aid implementation and management in building health

systems can bring about significant improvement in the breadth and quality of care provided, as well as in countries’ social and economic development. This is demonstrated best through the study of Rwanda and how the country has transformed its circumstance beginning from the ruins of the 1994 genocide to being “the only country in the region on track to meet each of the health-related millennium development goals by 2015” (Farmer et al., 2013).

The Vision 2020 policy, Rwanda’s comprehensive national plan, provides a clear, long-term development path and objectives for moving forward post-genocide. These comprehensive and transparent development plans allow for coordination among the government, donors, and implementing partners. Critical to the progress achieved is the strict adherence to country ownership and accountability, maintained in an effort to further national capacity building by “reducing the country’s dependence on external aid” (MoFEP, 2000). The Rwanda Aid Policy, published by the Ministry of Finance and Economic Planning in 2006, explicitly states, “The Government will decline any or all offers of assistance where it considers transaction costs to be unacceptably high, alignment to government priorities to be insufficient, or conditionalities to be excessive” (MoFEP, 2006). This ensures investment in national systems and institutions—investment that is beneficial to countries with weak institutional capacity (UN Office of the Special Envoy for Haiti, 2012).

This does not mean, however, that vertical funding from programs such as the Global Fund or the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) should be turned away. Instead, funds can be harnessed to build and strengthen platforms for integrated service delivery (Walton, 2004). In Rwanda, funds from PEPFAR, the Global Fund, and the U.S. Agency for International Development (USAID) were used to launch the Human Resources for Health program to combat shortages in health personnel with investments in health facilities and training (Binagwaho et al., 2013). Leveraging shared infrastructure, such as supply chain and procurement systems, laboratory capacity, health personnel, and information management also enabled greater efficiency in the system through improved access to care at lower cost (Farmer et al., 2013; Porter et al., 2009). Finding opportunities for funders to work in alignment with the government’s agenda have proven successful, with dramatic changes observed in poverty, life expectancy, spread of infectious disease, and child mortality (Binagwaho et al., 2014).

The Vision 2020 policy emphasizes reduction of inequality through improved access to high-quality health care and education, especially for previously neglected rural communities (MoFEP, 2000). Often, despite millions of dollars in aid, individuals who rely on the help of national institutions see little improvement in their situations. In the case of Sierra Leone, a country hugely impacted by the ongoing Ebola outbreak despite more than $712 million in aid, only 5 percent was funneled into national systems, therefore bypassing communities who would stand to benefit most (Office of the Secretary-General’s Special Adviser on Community Based Medicine and Lessons from Haiti, 2015). Rwanda has addressed this issue by implementing and managing its own effective system to track donor disbursements, based on recommendations from the Paris Declaration of Aid Effectiveness (UN Office of the Special Envoy for Haiti, 2012). Utilizing donors’ external aid-tracking systems instead of letting governments take ownership in tracking disbursement “undermines the government’s appropriation of the process and the validity of the figures” (UNDP, 2010). Including aid management and documented delivery in policy recommendations, such as in Rwanda’s Donor Performance Assessment Framework, allows for effective, timely, and high-quality data on aid programs and management (MoFEP, 2010). This holds the performance of donors accountable against “a set of established indicators on the quality and volume of development assistance,” ensuring the establishment of transparent dialogue, and “allow[s] for comparison, individual reflection on performance, accountability and peer pressure” among all involved partners (MoFEP, 2010). These data are essential for enabling the government to make evidence-based decisions to strengthen the public sector and effectively deliver public services (UN Office of the Special Envoy for Haiti, 2012). Rwanda observed 58 percent of its aid channeled into country systems in 2010, allowing for vast progress to be made in building and strengthening the country’s health system (UN Office of the Special Envoy for Haiti, 2012).

From this experience, we can also learn that bridging gaps in access to care for marginalized communities can be accomplished with community-based interventions quickly and at low cost. As of 2012, approximately 91

percent of the country was enrolled in the national community-based insurance scheme with subsidized premiums and co-payments on an income-based tiered payment structure that allowed for the poorest enrollees to obtain access to health care (Farmer et al., 2013). Strengthening community-based interventions by scaling up numbers of community health workers was accomplished rapidly and at low cost. These personnel are considered essential for bridging the health care worker gap through providing treatment, monitoring, surveillance, referral, and reporting services, and allowing for strong community linkages to be formed with the national health care system (Binagwaho et al., 2014). Rwanda’s inclusion of clear guidelines for financing, management, and delivery in its national policy has indeed helped overcome disparities in access to high-quality health care. It is important to keep in mind for the future that, as in the Ebola response, we have witnessed that where high-quality care was provided, Ebola patients survived. This is strong testimony to a national policy that builds a resilient, country-owned health system, thereby preventing future spread of disease and saving countless lives.

ANNEX 3-4

Acknowledging the Roots of Resistance and Distrust of Containment Measures

To understand community resistance and distrust of containment measures in Guinea, Sierra Leone, and Liberia during the Ebola epidemic, it is important to understand the history of public health approaches in the region. During the 2014 Ebola epidemic, journalists noted that establishing a cordon sanitaire was “a tactic unseen in a century” (McNeil, 2014). But restrictive and authoritarian tactics were used throughout the previous century by both colonial and independent governments. Outbreaks of yellow fever, smallpox, cholera, and bubonic plague joined the chronic affliction of malaria, and were met with a host of restrictive or punitive measures, including the destruction of housing, highly restrictive building codes and outright segregation, quarantine, isolation, and fines for infractions. These were all applied in discriminatory fashion, sparing Europeans in a manner that rankled Africans.

Ethnographic research as well as a survey of radio and print media suggest that citizens of all three countries have long-lived memories of prior campaigns to wall-off villages afflicted by smallpox, Lassa fever, influenza and even vector-borne diseases—such as plague, trypanosomiasis, and malaria.

In all three countries, wars had weakened already rickety public health systems, which were largely focused on restrictive and punitive measures and included little in the way of care; this was especially true in the eastern reaches of the “trizone area” in which the three countries come together. In Sierra Leone, the arsenal of measures taken to halt smallpox and malaria in the colonial period sounds eerily familiar to those seen in the recent Ebola response. These included fines (there was a two-pound fine levied on households “hiding” victims; the threat of mandatory quarantine within contagious disease “hospitals” with little in the way of medical or nursing care; other legal actions in 1914–1915, there were 1,333 “mosquito larva court cases,” even though the ditches and puddles remained ubiquitous); more futile and corrosive attempts to segregate Freetown; and efforts to restrict population movements (Cole, 2015; Rashid, 2011; Spitzer, 1968; Tomkins, 1994).

Similar approaches were adopted in French West Africa. Yet although the “sanitarians” were obsessed with disease control, this did not mean they were effective at controlling disease. Plague was in the end halted by more DDT and therapeutic advances, than by quarantine, travel bans, or the destructions of housing. Similar control-only approaches were applied to smallpox, and were often resisted (Greenough, 1995). Although the case-fatality of the disease varied widely, the primary approach to smallpox put all the emphasis on control rather than care: quarantine, isolation, ring vaccination, and walling off affected villages, which were sometimes razed. In both 1967 and 1968, Sierra Leone had the world’s highest incidence of smallpox among “all countries reporting to the World Health Organization” (Hopkins et al., 1971).

Caregiving did not, however, fit readily into the conceptions of the “sanitarians” of tropical medicine. Obsessed with disease control, they paid scant heed to supportive care. Their intense focus on containment and control and lack of interest in care left a potent legacy that undoubtedly influenced communities’ reactions to actions taken in the context of Ebola. Coupled with tensions remaining from recent conflicts in each of the three countries and the corrosive effects of corruption on public trust, this history of control-oriented public

health created a very challenging context for community engagement (Dhillon et al., 2015; Pellecchia et al., 2015; Richards et al., 2015).

Two lessons leap out: first that caregiving is an essential component of an outbreak response strategy, in part because it is the right thing to do, and in part because it is essential to enlisting community support; and second, that effective community engagement requires understanding the context, including the history, that will inform people’s attitudes and behaviors.

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