Strengths and limitations

The JEE established four important norms:2 (1) normalising a transparent process to examine and report on a country’s health security strengths and weaknesses; (2) setting standard definitions and scoring a country’s capacities in 19 technical areas; (3) involving governments and donors in strengthening those capacities across sectors and (4) prioritising opportunities for capacity development based on existing gaps. Over 110 countries,3 more than half of all WHO Member States have participated in the JEE. These assessments identified many critical health security gaps and actions to take.

In 2018, WHO released the JEE Edition 2 (JEE E2) to strengthen the tool based on country experiences and subject matter expert feedback. The updates maintained the original structure, while adding five indicators, merging four indicators, renaming three technical areas and clarifying interpretation of various attributes.4 Regional epidemics and the COVID-19 pandemic have highlighted gaps, some of which are not currently well represented in JEE E2. Improving measurement may involve changes to the JEE in these areas:

• Subnational capacity—the JEE is focused on national capacities, but national capacities are reliant on effective subnational or intermediate capacities. JEE E2 explicitly includes subnational capacities in National legislation, policy and financing (P.1.2), Food safety (P.5.1), Immunisation (P.7.1), National laboratory system (D.1.1), Surveillance (D.2.1), Reporting (D.3.2), Human resources (D.4.2–4), Emergency preparedness (R.1.1–2), Emergency response operations (R.2.1–3), Linking public health and security authorities (R.3.1) and Risk communication (R.5.2, R.5.4), but lacks articulated subnational capacities in other technical areas and a consistent approach across them.

• Safe health facilities—health systems cannot function when health workers are unsafe. Infection prevention and control (IPC) appears in JEE E2 as an indicator in Antimicrobial Resistance (P.3.3). One indicator is not enough and, therefore, Wilkason and colleagues propose that a new technical area should be created for safe health facilities or IPC to emphasise the importance of healthcare worker safety in global preparedness efforts.5

• Health equity and groups that have been marginalised—there is increasing evidence that groups which have been economically or socially marginalised, including racial and ethnic minorities, are disproportionately affected by COVID-19.6 7 WHO’s Commission on the Social Determinants of Health, Closing the Gap, articulated an expansive plan to address the complex web of determinants that contribute to health inequalities that can further fuel many infectious diseases.8 Quinn and Kumar propose that countries account for health inequalities in preparedness and response.9 Health equity is not currently addressed in the JEE E2, but evidence suggests that it could be considered.

• Case management—there is a critical link between case management, healthcare and health security. Case management appears in the JEE E2 in Medical Countermeasures and Personnel Deployment (R.4.3). Kluge et al propose that health security investments support universal health coverage by avoiding health crises that prevent patients from accessing healthcare (eg, health workforce diverted from regular care to focus on crisis response, health workforce is susceptible to infection during an infectious disease crisis or patients’ fear of contamination leads them avoid regular care).10 These linkages may warrant further exploration in the JEE.