Financing

Disease outbreaks are both lethal and costly. During 1997–2009, economic losses from six major outbreaks averaged $6.7 billion per year, and the cost of the 2014–2016 Ebola epidemic alone is estimated at $53 billion.3 Preparedness can prevent many outbreak-related costs, with estimated incremental worldwide expenditure of $4.5 billion per year needed to upgrade public health systems in low and middle-income countries, strengthen global institutions’ abilities to prevent and respond to emergencies, and invest in research and development of new vaccines, diagnostics and countermeasures for epidemic and pandemic-prone diseases.4

Unfortunately, preparedness, although more effective and less costly than response,5 rarely ranks high on political agendas. Competing priorities for finite national budgets, along with the invisible outcome of successful preparedness, have resulted in little funding, despite an estimated 25%–88% annual return on investment.6 Vulnerable lower income countries have bigger gaps and greater need for external financing. Of the 24 least-prepared countries,2 20 (83%) are sufficiently low income to be eligible for International Development Association (IDA18) from the World Bank.7 In these countries, there are limited resources and competing demands, with the result that public health is often a low priority.8 The World Bank has recently dedicated additional support for health security in these settings through specific IDA projects such as the Regional Disease Surveillance Systems Enhancement project.8 Regional development banks can develop similar credit or grant programmes to build public health capacity in countries and protect regions from the economic shocks of large-scale outbreaks, as the Asian Development Bank has done.9

Prioritisation

Stepping up preparedness is difficult, and requires that many incremental activities be done to achieve meaningful change. This is nearly impossible without prioritisation, and countries need coherent guidance and practical tools to identify where to begin. To reduce epidemic risk, countries must ensure prioritisation of core capacities of laboratory, surveillance, workforce and emergency response operations, as well as critical enabling areas including emergency preparedness, risk communications, and national legislation, policy and financing. Countries can use information collected from JEEs, annual self-evaluations of preparedness, risk assessments and evaluations of real and simulated events to identify specific vulnerabilities and urgent actions to take next. Recently, the WHO and partners developed a library of key sequential activities necessary for countries to move from one preparedness level to the next.10 By combining practical technical guidance with improved prioritisation, countries can move more rapidly from assessment to improvement.

Management

Preparedness activities are implemented by the government, often supported by donors, bilateral and non-governmental organisations. Donors and governments often prefer tangible and highly visible support, such as building Emergency Operations Centers, without means to support ongoing operational costs and human resource requirements. By focusing on specific key activities informed by preparedness assessments, partners can help build the basic systems necessary to find, stop and prevent disease outbreaks. Unless partners also support management, human resources and strengthening of administrative systems, many countries are unlikely to efficiently and effectively implement plans. Strengthening management, improving technical expertise and advocating for increased long-term domestic financing should be a part of every engagement. Leadership and management skills are essential to planning and implementation, but their development is often eclipsed by a focus on more ‘technical’ skills. Management within health systems is particularly important in low-income settings, where efficient use of limited resources is critical to accomplish health goals.11–13 Those charged with leading preparedness activities need effective tools and skills to plan, implement and report on complex multisector National Action Plans for Health Security (NAPHS) across all 19 technical areas. On average, it has taken 420 days for countries to conduct a JEE and then release a finalised NAPHS, which is not yet linked to resource mobilisation. Cumbersome and lengthy planning processes not effectively linked to resource mobilisation have hindered implementation of gap-filling activities.

To develop expertise in preparedness, the routine evaluation of detection and response performance in real or simulated events should be common practice. Use of after-action reviews,14 and, where necessary, robust simulation exercises, as well as monitoring the timeliness of outbreak detection, response and control15 enables countries to strengthen systems for an unusual or larger event. These reviews can also help identify bottlenecks to effective response, such as inadequate community engagement and geographic or demographic groups that distrust government action which may require concerted, long-term efforts to address.

At the onset of the West Africa Ebola epidemic in 2014, most countries did not have Public Health Emergency Operations Centers (PHEOC). Since then, more than 20 such centres have been established in Africa, with substantial support from regional and international partners. Unfortunately, many of these structures are not fully functional and lack key components, including information management systems and full-time, trained staff. Many PHEOCs are used primarily as spaces to conduct large meetings, with a high threshold for activation leading to underutilisation. Emergency response capacity, including emergency operations centres, will be most effective if used regularly for a broad spectrum of events, ranging from everyday ‘watch’ activities including disease surveillance, resource management and functional exercising, to response, including incident management and coordination of response to outbreaks and other health hazards.