Following the West Africa Ebola virus disease outbreak (2013–2016), the Joint External Evaluation (JEE) is one of the three voluntary components recommended by the WHO for evaluating the International Health Regulations (2005) capacities in countries. Here, we share experience implementing JEEs in all 47 countries in the WHO African region. In February 2016, the United Republic of Tanzania (Mainland) was the first country globally to conduct a JEE. By April 2022, JEEs had been conducted in all 47 countries plus in the island of Zanzibar. A total of 360 subject matter experts (SMEs) from 88 organisations were deployed 607 times. Despite availability of guidelines, the process had to be contextualised while avoiding jeopardising the quality and integrity of the findings. Key challenges were: inadequate understanding of the process by in-country counterparts; competing country priorities; limited time for validating subnational capacities; insufficient availability of SMEs for biosafety and biosecurity, antimicrobial resistance, points of entry, chemical events and radio-nuclear emergencies; and inadequate financing to fill gaps identified. Key points learnt were: importance of country leadership and ownership; conducting orientation workshops before the self-assessment; availability of an external JEE expert to support the self-assessment; the skills, attitudes and leadership competencies of the team lead; identifying national experts as SMEs for future JEEs to promote capacity building and experience sharing; the centrality of involving One Health stakeholders from the beginning to the end of the process; and the need for dedicated staff for planning, coordination, implementation and timely report writing. Moving forward, it is essential to draw from this learning to plan future JEEs. Finally, predictable financing is needed immediately to fill gaps identified.
- Health systems evaluation
- Public Health
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WHO Member States are required to assess their emergency preparedness and response capacities under the International Health Regulations (IHR) (2005) and to fill any critical gaps identified. The Joint External Evaluation (JEE) provides a useful process for identifying the available IHR capacity gaps. All 47 Member States in the WHO African region have conducted a baseline JEE.
While there is global guidance on the JEE process, the context of its implementation varies from one country/region to another. This paper describes the strategy used by the WHO African region to support the implementation of JEEs in all its 47 Member States.
There is a need to learn from previous JEE implementation as countries initiate the second round of JEE implementation. Importantly, there is a need to leverage on the best practices to improve the second round of JEEs, while anticipating the common challenges to inform global and regional guidance on the JEE process. Post the -JEE, 46 of 47 countries developed the National Action Plans for Health Security (NAPHS)to address the gaps identified. However, a major challenge remains when mobilising the required financial resources to implement them. Moving forward, it will be essential to address these challenges and draw from the lessons learnt to plan the next round of JEEs. Importantly, the low and middle-income African countries may be reluctant to conduct additional assessments unless there is a foreseeable funding source. Learning from the baseline JEEs, as well as the intra-action reviews (IARs)for the COVID-19 pandemic in Africa, there is an urgent need to establish a predictable and flexible financing mechanism for pandemic prevention, preparedness, and response. Such funding mechanism should integrate building resilient health systems for universal health coverage to avoid verticalizsation of health security strategies in Africa.
The International Health Regulations (IHR) were first adopted by the 22nd World Health Assembly (WHA) in 1969, from what were previously known as the International Sanitary Regulations.1 The current version of the IHR (2005) was adopted by the 58th WHA on 23 May 2005 and entered into force on 15 June 2007.2 3 The purpose of the IHR (2005) is ‘to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade’.2 The IHR (2005) offer the framework for the prevention and control of epidemic and pandemic threats and enable countries to defend themselves against health security risks and emergencies.2
Origin of the Joint External Evaluation
Between 13 July and 15 July 2015, a high-level meeting, attended by close to 200 national and international experts, was held in Cape Town, South Africa, with the theme ‘Building health security beyond Ebola’. This meeting reviewed some of the lessons learnt from the West Africa Ebola epidemic, including the following: (1) disease surveillance and safe essential services must be available and operational at community level; (2) sectors outside health often influence health, negatively or positively; (3) self-assessment of IHR capacity is insufficient and evidence-based tools are needed to assess countries’ IHR capacities; (4) strong national leadership is needed in outbreak situations; (5) religious leaders and traditional healers who are respected in the community may be able to support responses; and finally, (6) a successful outbreak response can be the basis for improved future preparedness.4 As a next step, the Cape Town meeting mandated the WHO to spearhead global efforts and to propose a collective, coherent and synergistic approach among international and national stakeholders supporting joint assessments in countries, and to develop, implement and test national plans. Based on IHR review committee recommendations, in 2015, the WHO developed a concept note for a revised IHR monitoring and evaluation framework (IHRMEF) comprising of the existing one mandatory component (States Parties Annual Reporting (SPAR)) and three new voluntary components (after action review (AAR), simulation exercises and external evaluation (SIMEX)). A technical consultation in Lyon in October 2015 led to the development of the Joint External Evaluation (JEE) tool based on the existing WHO tools and various regional strategies and other initiatives, such as the Global Health Security Agenda (GHSA) assessment tool and the World Organisation for Animal Health Performance of Veterinary Services (OIE PVS) Pathway.5–7 Consequently, the IHRMEF, previously based on a mandatory self-assessment report, was revised to provide broader approaches for countries to review the implementation of their public health capacities under the IHR (2005).8 9 The IHRMEF ensures the mutual accountability of States Parties and the WHO Secretariat for global public health security through transparent reporting and dialogue. At present, the framework comprises four components: a mandatory SPAR and three voluntary components, namely AAR, SIMEX and the JEE.8
The JEE is a voluntary, multisectoral process to assess country capacity to prevent, detect and rapidly respond to public health risks.9 The JEE allows countries to identify the most urgent needs within their health security system; to prioritise opportunities for enhanced preparedness, detection and response capacity, including setting national priorities; and to allocate resources based on the findings.9 Collectively, these capacities are known as ‘health security’.10 The JEE tool and process have been developed and implemented in full concordance and collaboration with related efforts such as the GHSA and the OIE PVS Pathway.7 The JEE is a peer-evaluating approach involving subject matter experts (SMEs) and their in-country counterparts reviewing previous assessment findings and available data to agree on JEE capacity scores in line with the JEE tool. The JEE process ensures transparency through openness of data and information sharing, including the public release of the JEE report.9
Following the JEE, the country is expected to develop a plan of action to increase or maintain the validated JEE capacity scores. This is commonly called the National Action Plan for Health Security (NAPHS), which is a strategic plan resulting from the recommendations for priority actions of the JEE report. In most cases, African countries formulated 5-year plans with indicative cost estimates.11 The NAPHS is then used to develop operational plans over a 1-year or 2-year period.11 Unlike the JEE reports, many NAPHS plans are not found in the public domain. Moving forward, it will be prudent for all Member States to publish their NAPHS like it is done for the JEE reports. This will facilitate a robust analysis of the regional and global financial requirements for health security in Africa, which could be used for advocacy and formulation of resource mobilisation strategies from traditional and new internal and external sources.
In a previous publication, we presented an analysis of the baseline JEE/IHR capacity scores in the WHO African region.12 In this follow-up paper, we share our experience in supporting all 47 (100%) Member States to conduct the baseline JEE. We present the best practices, lessons learnt and the challenges. We believe that this paper is timely because it offers perspectives for the future as countries embark on a second round of JEEs,13 as well as Universal Health and Preparedness Review.14 Importantly, this paper offers insights to future proposals for the IHRMEF that is being deliberated by the working group to amend the IHR (2005).15
The JEE process in the WHO African region
Voluntary approach alone or combined with soft diplomatic advocacy
The JEE process was designed to occur in six phases, and each phase is designed to take a certain time (figure 1).13 Although there is a suggested time frame, this was entirely dependent on the country context. There is a standard checklist to monitor the progress across these phases and in the WHO African region, all these steps were always followed.13 The main adaptation was in the initial step. While most countries volunteered to conduct the JEE, several of them needed some soft diplomatic advocacy. In such instances, we deployed advance teams to have discussions with high-level government policymakers and relevant stakeholders on the value of conducting a JEE as part of the IHRMEF. This proactive action led to the conduct of a JEE in all 47 countries plus in the island of Zanzibar which is part of the United Republic of Tanzania.
Adaptation of the standard checklist
While there is a standard JEE checklist, not all items on the checklist were possible to realise systematically. For example, having a meeting with the external team prior to arrival in the country for the JEE was often not possible because of the diversity of the team both technically and by location, conflicting agendas and challenges with the internet. It was not always possible to agree on a good time for the virtual team meeting. It is worth noting that most JEEs were conducted between 2016 and 2019 when Zoom, Teams and other virtual meeting services were less popular. After the COVID-19 pandemic, this may not be a challenge anymore.
Orienting potential SMEs and training team leads
The first JEE in the world was conducted in Mainland Tanzania in February 2016.16 During the JEE in Mainland Tanzania, we identified the need to have trained team leads and to orient additional SMEs as a few SMEs were overwhelmed by leading several technical areas. Learning from the challenges in Mainland Tanzania, WHO and GHSA partners identified and trained a pool of SMEs and team leads to conduct the JEEs.
Setting annual targets for the number of JEEs to be conducted
Following the pioneer JEE in Mainland Tanzania, other JEEs were conducted in Ethiopia (March 2016) and Mozambique (April 2016). For these initial missions, the planning and coordination were done by Deloitte Consulting. As of June 2016, we had conducted three JEEs. However, the target for the year was to support 10 countries to conduct JEEs. These 10 countries included three emergency preparedness and response priority 1 countries—Liberia, Sierra Leone and Guinea—following the end of the Ebola virus disease outbreak in 2016. The reason for lagging behind was attributable to the high demand and competing priorities of the limited trained SMEs and team leads available globally to carry out these missions. The delay was also due to the JEEs being voluntary13; this meant that countries had to decide if they want to do the JEE, why and when. The WHO and partners had to demonstrate the value added to Member States, as well as cover the costs of conducting the JEE. The WHO conducted training for additional team leads and developed an online module for orienting potential SMEs to constitute teams for each JEE mission.
Duration of the external evaluation missions and field visits
The duration of most missions was 7 days. In a couple of countries, we were faced with a 4-day work week instead of the regular 5-day work week. This was due to national holidays that were not foreseen during the selection of the week of the evaluation workshop. On the other hand, due to the government structure and surface area of one country, the mission took 7 working days. This is because major points of entry, especially ground crossings, laboratories (human and animal health) and reference health facilities were in a different state or region from the location of the workshop.
A main event during the evaluation week was the field visits on the fourth day of the workshop. Depending on the country context (size, security, administrative nature of the government and health system organisation), the number of sites proposed for the field visits and the size of the external team, this can be a daunting task to set up and coordinate. The greatest challenge was usually the logistics involved in visiting ground crossings. Some of the important ground crossings were sometimes hundreds of miles away from the location of the workshop. In some cases, the insecurity compounded the distance challenge.
Dedicated consultant to manage the JEE portfolio
Because of the increasing workload in scheduling JEEs and rostering SMEs, in July of 2016, a consultant was recruited at the regional office to specifically manage the JEE portfolio as a primary responsibility. The role of the consultant was to take over the responsibilities from Deloitte Consulting, and plan, coordinate and implement the remaining seven JEEs targeted for 2016. The organising of the JEE meant several email exchanges and phone calls, and in some cases, in-person visits to conduct soft diplomacy to get the countries to volunteer and officially request to do the JEE and to mobilise various stakeholders (national and international), ensuring all sectors are engaged based on the One Health approach at the very beginning of the process at country level17; ensuring understanding of the JEE tool, process and context; rostering of external SME to make sure that all 19 technical areas were covered but at the same time avoiding a very big team of external validators; coordinating teleconferences with the national counterparts and the external evaluation teams; handling the logistics of getting the external team in-country on time for the preparatory meeting and the evaluation workshops; and ensuring the availability of working documents—presentations and reference documents—ahead of the workshop. The above were some of the tasks carried out in the planning and coordination. Many other such tasks are stipulated on the checklist for each of the steps (figure 1).
Following the recruitment of a dedicated consultant, an additional six JEEs were completed in 2016, bringing the total number to 9 out of the targeted 10 JEEs, making 19% of the total planned JEEs but 90% of the target for 2016. In the subsequent years, the number of JEEs completed increased markedly relative to the targets (60% in 2017, 81% in 2018, 98% in 2019 and 100% by March 2022). Thus, the target of 80% JEEs conducted by 2018 in the WHO African region’s Strategy for Health Security and Emergencies, 2016–2020, was attained and surpassed by a percentage point by 2018.18 It is worth stating that the JEE coverage in the WHO African region as of December 2022 was 100% compared with 6–81% in other regions (table 1). Once dedicated staff were recruited at the regional level and at the Dakar and Nairobi hub, the services of the consultancy firm were discontinued. These dedicated staff were solicited for SMEs from WHO, Africa Centres for Disease Control and Prevention (CDC), the US CDC, Food and Agriculture Organization of the United Nations (FAO), OIE, GHSA partners, including from academia and Member States, to support the JEEs in each country. While some SMEs were offered consultant contracts for the period of the JEE, others from the GHSA partnership and donor institutions were not.
Role of the WHO country offices
For a country to conduct a JEE, it must make a request to the WHO. This request is submitted to the WHO regional office via the country office. A prerequisite to conduct the external evaluation is to have completed a self-assessment. The WHO country offices play a crucial role in ensuring that the two steps above are done in a timely manner. The WHO country offices provide technical, logistical, and in some countries, financial assistance to conduct the self-assessment. Without the collaboration of the various WHO country offices, it would be very daunting to follow up all these processes in multiple countries at the same time from the regional office in Brazzaville or from the WHO headquarters in Geneva. The country offices are the go-between for the regional offices and headquarters and the governments. Once the self-assessment is completed, it is submitted to the regional IHR Secretariat by the WHO country office. The country office then proceeds to prepare for the on-site visit by the external team, including preparations for the field visits.
Selection of external SMEs
Identification and rostering of SMEs for each JEE mission was another major task. A total 360 SMEs from 88 different organisations were deployed 607 times to participate in the 48 JEE missions (table 2). While some SMEs were available only once, others participated in more than one JEE (table 3). The median number of SMEs per mission was 12 (range: 8–15). There were 22 team leads with one extraordinary team lead that led 15 JEE missions, while there were 36 co-team leads.
Report writers and the need to translate all tools to the appropriate language
After conducting 11 JEEs, we recruited a report writer/editor who supported the compilation and editing of the JEE report. The Mauritania JEE was the first of such nature in the region. Senegal was the first Francophone country to conduct a JEE, while Sao Tome and Principe was the first Lusophone country of the five in the region and globally to do the JEE in Portuguese.
Some of the major challenges were adjusting to sudden changes in schedules or programming due to a national holiday or a national authority changing the schedule or a last-minute conflict in the agenda. It was common for set dates for the external evaluation phase to be changed (brought forward or pushed further). This situation sometimes affected the availability of SMEs on the team, leading to a search for replacements. In some countries, we had to adapt the calendar of the week to accommodate a public holiday, reducing the work week from 5 to 4 days.
Another challenge was lack of representation of all relevant sectors involved in the implementation of the IHR due to poor communication and coordination at national level. These circumstances led to limited expertise in the session for key technical areas which resulted in delays or limited ability to assess the real capacity of the country in that technical area, as those present lacked the relevant experience and expertise.
Further, there was irregular attendance during the workshop, especially for workshops that took place within the city of residence of the participants’ workplace. Participants would multitask in the evaluation sessions because they had competing obligations or multiple functions with limited human resources. Often, the country counterparts would get summoned to their regular office jobs because they were within reach.
Managing diverse personalities and temperaments within the external evaluation team was another challenge. Team dynamics comes into play at various stages of the external assessment process. Managing teams of 12–19 experts from different parts of the world with differences in opinions, ideas and personalities is challenging. Good leadership and interpersonal skills are required to manage such teams.
Identification of SMEs who speak French, Portuguese or Spanish for the Francophone, Lusophone or Spanish-speaking countries, respectively, was often a challenge. In our region, there are three official languages—English, French and Portuguese. However, there is one country whose official language is Spanish. Most workshop training materials were conceived in English, making it challenging for those who do not use English as the official language. Moreover, the first set of experts trained were English speakers only.
Absence or delayed translation of guides and tools into French, Portuguese or Spanish led to delays in conducting JEEs in some countries, because all documents were initially conceived in English.
High turnover of national experts in various sectors resulted in loss of institutional memory. Moreover, the lack of understanding of the IHR, the JEE process and ownership by some country IHR National Focal Points also affected the smooth conduct of some JEEs.
Finally, competing priorities and agendas at national level and among partners led to difficulties in agreeing on the need for the JEE and the dates for the various phases. This in turn made it hard to set up the external evaluation well ahead of time for some missions.
Despite the above challenges, we observed several best practices including organising an orientation workshop to kick off the self-assessment process with the help of understanding the IHR and the JEE process. It gave room for stakeholders to have a common understanding of the JEE process, the tool, the terminologies and scoring criteria. While some national experts could have been exposed to the IHR and associated guides and tools, many were encountering this, or making the connection to their work areas, for the first time. This resulted in more reliable self-assessment reports and preparations towards the external assessment.
The translation of the guides, templates and tools into French, Portuguese and Spanish and identifying native and advanced speakers with the expertise in the 19 technical areas of the JEE missions to French, Portuguese or Spanish-speaking countries fostered ownership of the process and promoted peer-to-peer dialogue in the countries. All the documents produced by the WHO are primarily in English. While some get immediate translation into French, sometimes, the WHO Africa regional office had to do the translation of others, especially into Portuguese, which is not one of the WHO’s official languages. But we have Portuguese-speaking countries in the region.
The availability of the global roster of IHR experts from which to find SMEs eased the process of identifying team members. The roster had experts who had already done JEE missions or had been trained to conduct these missions or had taken the online orientation course and scored at least 80% to obtain a certificate of completion.
During the external evaluation missions, identification of national experts to use for missions in neighbouring countries promoted capacity building and experience sharing among countries in the region. These experts were subsequently included in the global roster based on their experience in conducting the JEE. They also took the online orientation exercise.
The availability of a writer/editor on the team to assist with the writing, compilation, formatting and editing of the JEE report reduced the time it took to produce the reports after the missions. This also made work lighter on the team lead. Before this initiative was implemented, it was the sole responsibility of the team lead to produce a report good for submission for publication. This proved to be a challenge as most team leads would go back to their daily routine which, in most cases, was already very hectic. With the support of the team writer/editor, the team lead would have to review a well-advanced draft.
Organisation of workshops for the training of team leads increased the pool of experts for leading JEE missions. Two of such workshops were organised. Further training was done while on mission, as the co-team leads were trained to become leads.
Inviting national experts and authorities from aspiring countries to observe the JEE process of another country gave reluctant countries a first-hand experience on the process and its outcomes. This broke the barriers and clarified the myths about the JEE. Those countries subsequently carried the JEE.
Some SMEs from partner/donor institutions who participated in JEEs identified potential technical areas for subsequent support by their institution during JEE process. This meant that there was funding readily available to cover the gaps identified during the assessment.
The JEEs created a platform for strengthening collaboration between the animal and human sectors. In some countries, there was limited interaction between the two sectors before the JEEs. However, the JEE created an opportunity for various sectors contributing to the IHR implementation to be in the same room and discuss their capacities, strengths and challenges as a country.
The diversity of the external evaluation team, with experts from the WHO and partners, as well as various institutions including academia, resulted in the implementation of the One Health approach in the assessments and subsequent planning. This brought to light the multisectoral and multidisciplinary nature of IHR implementation.
Organising an orientation workshop at the beginning of the self-assessment process proved very essential in dissipating myths. It also served as an ice breaker for the entire process.
At the end of a well-planned and coordinated JEE, there is a sense of fulfilment and establishment of a platform for the coordination of the implementation of the IHR. This results from the gain in knowledge of the multisectoral nature of the IHR, the multisectoral team of both national and external experts. In some cases, the JEE served as a learning experience especially for those from outside the human health sector.
It is essential to involve all stakeholders from the beginning of the JEE process and to keep communication flowing among stakeholders. This ensures buy-in, improves collaboration and promotes sustainability.
The planning, coordination and implementation of the JEE require dedicated staff to meet the targets.
Perspectives for the future
First, national and global stakeholders should ride on the momentum from the baseline JEEs, as well as the momentum from the COVID-19 intra-action reviews19 to support African countries to review and implement national action plans to fill the gaps identified and fulfil the recommendations from the JEEs.
Second, as demonstrated by the COVID-19 pandemic, there is an urgent need to map and mobilise financial, logistical and human resources immediately to implement the revised plans.
Third, there is an urgent need to build or strengthen the multisectoral team dynamics observed during the JEE process to establish sustainable coordination mechanisms for One Health implementation.
Fourth, all countries should build on the challenges and lessons learnt while planning for the baseline JEEs and developing action plans to conduct a second round of JEEs and subsequently formulate shorter-duration action plans (preferably 3-year costed plans). This should take into consideration lessons learnt in responding to the COVID-19 pandemic.
The experience and challenges of conducting JEEs in the WHO African region were presented to the team reviewing the JEE tool, and the need for subnational assessments has to a certain extent been incorporated into the JEE tool V.3.
The WHO African region has led the WHO reforms in health emergencies. The West Africa Ebola virus disease outbreak was a huge crisis; however, it also offered an opportunity to build a new preparedness and response culture with new tools. We commend African countries for their leadership and ownership of the health emergency reforms. For example, post-JEE, 46 of 47 countries in the WHO African region developed NAPHS to address the gaps identified (figure 2). We believe these health emergency reforms in Africa prepared the countries for other health emergencies, including the COVID-19 pandemic. However, a major challenge remains when mobilising adequate financial, logistical and human resources to implement the reforms on a large scale. Moving forward, it will be essential to address these challenges and draw from the lessons learnt, as well as those from the COVID-19 pandemic response to fast track health emergency reform in Africa. We call upon national and global stakeholders to establish a predictable and flexible financing mechanism for pandemic prevention, preparedness and response in Africa that integrates strategies for health security with those for building resilient health systems that can withstand any shocking events.
Finally, for the IHR (2005) and health security, the key technical areas for which capacity strengthening is needed have been clearly stipulated.20 In the same vein, the key technical areas for building and sustaining resilient health systems need to be stipulated beyond theoretical concepts to pragmatic capacity assessment tools and planning guides for the peripheral, district, and national policymakers and implementers.21 22 The case for embedding global health security into resilient health systems for universal health coverage has been made several times.6 23 24 We need to act now to mitigate the impacts of future epidemics and pandemics.
Data availability statement
Data are available in a public, open access repository.
Patient consent for publication
No research was conducted on human and animal subject. Countries involved in this study voluntarily requested for the WHO support through their government.
We would like to acknowledge the active participation of national experts from all the volunteer countries, the members of the international roster of experts (over 1000 of them) and the invaluable partnerships with governments including the governments of Finland, Germany and the USA; with other intergovernmental organisations, particularly the Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (OIE) and the International Civil Aviation Organization (ICAO); many public health institutions such as the US Centers for Disease Control and Prevention (US CDC), the Africa CDC, Resolve to Save Lives, the European Centres for Disease Prevention and Control (ECDC) and Public Health England (PHE); private entities such as the Bill and Melinda Gates Foundation and many other partners, including the members of the Global Health Security Agenda and of the JEE Alliance. We would like to acknowledge the continuing support and commitment of all of these to the implementation and principles of the International Health Regulations (2005). Finally, we thank the Member States for their ownership and leadership in volunteering to conduct the JEE.
Handling editor Seye Abimbola
Contributors I-SF was the director of the emergency programme during the time the work was done. RKW planned, conducted and reported on the work described in the article; collected all the data and prepared the manuscript; and is the guarantor of the paper. AAY supervised and participated in the work reported in the article. VFN critically reviewed the article prior to submission. MS, AM, MN, BLH, AL, JM, DY, ABD, S-AO, CN, AO, GAK and ZY participated in the conduct of the work described in the article. CM developed all the tables and figures in the article. DC supervised the finalisation of the article and supervised the work done in the latter stages. AT led 15 JEE missions, participated and supervised the conduct of the work described in the article, and extensively revised the manuscript.
Funding Most of the funding for the JEEs was from the WHO, the European Union and the US CDC. The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Disclaimer The author is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the World Health Organization.
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Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.