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How prepared were we?

A reflection on how well prepared we were – or thought we were – to face a pandemic like COVID-19, which we knew one day would come.
In week two we looked at the health system response to COVID-19, and touched on epidemic or pandemic preparedness. Here, we explore a little more about what we knew, or thought we knew, about how prepared we were to face a pandemic like COVID-19, drawing on a number of different assessment approaches, The Global Health Security index assesses countries’ health security and capabilities. There are 140 index questions across six categories, including prevention, detection and reporting, rapid response, health system compliance with international norms and risk environment The index does not simply measure preparedness for pandemics, but has a much wider remit for biological risks that threaten national and regional stability, economic consequences, and increased morbidity and mortality.
The index has a solid reputation, having been produced by leaders in global public health, such as Johns Hopkins University and funded by influential organizations like the Bill and Melinda Gates Foundation. The most recent data available from the index was from 2019, of which the summaries are included in this slide. In terms of pandemic preparedness, it was found that national health security is fundamentally weak around the world. No country is fully prepared for epidemics or pandemics, and every country has important gaps to address. Countries are not prepared for globally catastrophic biological event. There is little evidence that most countries have tested important health security capacities or showing that they would be functional in a crisis.
Most countries have not allocated funding from national budgets to fill identified preparedness gaps. More than half of all countries face major political and security risks, that could undermine national capability to counter biological threats
Most countries lack of a foundational health system capacities, vital for epidemic and pandemic response. Coordination and training are inadequate, among veterinary, wildlife and public health professionals, and policy makers. And improving country compliance with international health and security norms were stressed as essential. We will return to how valuable the index has been in predicting health security and preparedness regarding specific national health systems later on.
In 2020, The Lancet published a paper from a study, which aimed to review existing health security capacities against public health risks and events based on data from 182 countries. It found that countries vary widely in terms of their capacity to prevent, detect, and respond to outbreaks. Around half of all countries analyzed, have functional operational readiness capacities in place, at both national and sub-national levels, which does suggest that an effective response to potential health emergencies like COVID-19 could have been enabled in these countries. This is shown in the top image on the left of this slide, that shows that the majority of countries were classified as level 4 or 5, which the blue and the yellow bars.
The specific definitions for each level are provided in full detail at the bottom of the slide. When looking across WHO regions, which is the image on the right here, you can see a stark variability and functional capacity in place to prevent and control risks or events, with European countries seemingly having the strongest readiness capacity and Africa the weakest. It is important to remember, however, the findings from local risk assessments or retrospective evaluations, are needed to fully understand national readiness capacities in relation to COVID-19. Capacity building and collaboration between countries are also needed to strengthen the global readiness for outbreak control
So now to look at the country level, the Joint External Assessment or JEEs are the most common way to assess country capacity to respond to public health risks, occurring naturally or due to a deliberate or accidental events. They are intended to be pursued as a voluntary, collaborative multi-sectoral review process. Generally, large variations in JEEs scores are found among countries and WHO regions. Here, we present some common findings from JEEs. Emergency preparedness is directly related to the quality of the health system in a country, and the amount of resources used to strengthen it. Although some countries are reasonably well prepared, many do lack basic health basic systems to find stop and prevent infectious disease threats.
Many are developing national action plans but have yet to actually implement them. The results of these assessments have shown that many countries have strong immunization programs, disease surveillance, and laboratory networks. This, likely reflects the financial resources provided by global donors and the technical assistance developed in these areas. In contrast, critical areas such as legal frameworks, financing, disease-specific assessments and planning, emergency response operations, are the weakest. This includes laws that set a legal precedent for disease control and preparedness, as well as activation and mandate of emergency operations centers. Without these critical pieces, countries remain unprepared and unable to adequately protect their people, neighboring countries, and therefore, the rest of the world, as we have seen with the case of COVID-19.
Nearly half of all countries who completed JEEs are in the WHO African region, with 91 percent of African countries having completed that assessment. However, African countries have the lowest average JEE score, 41 on a scale of 100. For example, the Democratic Republic of Congo scored only 35 percent in this recent assessment. This slide summarizes some data from a JEE conducted in DRC last year, which may reflect the enhanced insight from the recent Ebola pandemic, as well as the detrimental impact the pandemic had on the health system. As you can see, there are a number of very critical gaps. There’s an urgent need to strengthen laboratory and testing capacity.
In terms of enabling provision of a broader range of priority diseases, creating a transport system, which would enable lab samples to be transferred, from up to 80 percent of health facilities to the national laboratory, and to boost quality control through their testing program. Again, with a focused on priority disease. There is a need to strengthen disease surveillance, to train health workers across the board, to monitor and detect potential disease cases, and to follow a clear protocol should a potential threat be identified, There is a need to boost the quality in the collection, and aggregation or summation of surveillance, or case data, and the regular reporting of disease cases.
In relation to human resources, an effort to compile a list of all national experts in various epidemic and preparedness response efforts was recommended, so the national capacity could be known. And therefore, effectively utilized. It was also recommended that job descriptions be prepared for local level rapid response teams and public health officers, to enable surge capacity and recruitment, and roll out of these front line teams as soon as the need arose. Finally, in the area of emergency response operations, an area highlighted through the summary of JEE findings across countries, it was recommended to boost preparedness, by developing now an emergency operations centre to act as the coordinating hub in the event of an emergency.
Also prioritization needs to be given to the evaluation of coordination and response efforts post event, so lessons can be learned and applied to boost preparedness and response in future events. As mentioned, later this week we will come back to how useful these preparedness assessments have been with the knowledge we now have on how well our health systems have coped with COVID-19 so far.

In this video, we explore some key approaches to assessing epidemic preparedness and consider how prepared we thought we were to face a threat like COVID-19. We look specifically at the Global Health Security (GHS) Index and the recommendations made last year to boost epidemic preparedness, as well as the limitations of the GHS Index in really understanding national readiness capacities in relation to COVID-19. We then look at the most frequently made recommendations from Joint External Evaluations (JEEs) which assess country capacity to respond to public health risks. We give particular focus to the Democratic Republic of Congo as one example.

After watching this video, please consider two aspects.
Firstly, while it may be expensive to invest in epidemic preparedness, what may be the trade-offs of not doing so?
Secondly, how aligned do you think epidemic preparedness and severity of the actual outbreak may be? Is it possible that the reality of the response could be quite different to what the preparedness ratings would suggest and if so, why?

We will return to these questions later on this week.

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COVID-19: Global Health Perspectives

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