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Summary box
The International Health Regulation core capacities are essential for detecting, assessing, notifying, reporting and responding to public health risks and events of national and international concern.
The IHR States Party Self-Assessment Annual Reporting tool data reflect the level of performance or achievement of each core capacity area.
Between 2018 and 2020, an analysis of SPAR scores in low-income and lower-middle-income countries identified six low scoring IHR core capacities: food safety, health service provision, risk communication, points of entry, chemical events and radiation emergencies.
Low-income and lower middle-income countries should prioritise efforts to improve existing IHR-related policies and mechanisms based on evidence generated through operational and implementation research, with a specific focus on these low-scoring capacity areas.
Introduction
Recent epidemics and pandemics such as COVID-19 have illustrated that the world is ill prepared to address the impacts of health emergencies with significant inequalities across regions and countries.1 2 Most importantly, health emergencies disproportionately affect low-income countries (LICs) and lower-middle-income countries (LMICs), exerting the greatest adverse impact on health, social and economic sectors.
The International Health Regulations (2005) (IHR) mandates States Parties (SPs) to develop minimum core capacities and annually report capacity level to the World Health Organization (WHO) using the States Party Self-assessment Annual Reporting tool (SPAR). The first edition of SPAR (2018) measured the performance or achievement level across 13 IHR core capacity areas to prevent health emergencies or mitigate their impact.3 We aimed to review and identify low scoring IHR core capacity areas within LICs and LMICs. The identification of common scoring patterns among LICs and LMICs can highlight shared challenges in IHR implementation and pinpoint focus areas for operationalisation research to strengthen health emergency capacities.
Using publicly available SPAR data, we retrospectively reviewed scores from 2018 to 2020 among 73 WHO SPs who met World Bank classification as LIC or LMIC.4 SPAR data after 2020 were excluded due to indicator changes in the second edition being incomparable to previous years.5 SPAR scores were available for 13 core capacity areas composed of 1–3 individually scored indicators. Each score is categorised into five levels based on the country’s progress towards implementation of IHR capacities, level 1 (lowest capacity) to level 5 (highest capacity). Each IHR core capacity area was reviewed and classified as low scoring when at least half of the 73 SPs scored level 2 or below in two or more assessment years.
Six low-scoring IHR core capacities
We identified 6 of 13 IHR core capacities to be low scoring: food safety, health service provision, risk communication, points of entry (PoE), chemical events and radiation emergencies (figure 1). This means more than half of LICs and LMICs have limited policies/mechanisms for almost half of all IHR core capacities.
Classification of 73 low-income and lower-middle-income SPs by IHR capacity level for years 2018, 2019 and 2020. The horizontal blue line indicates where half of the SPs lie (36 of 73 included SP). IHR technical areas with low scores areas are indicated by the blue line crossing the pale yellow (Level 2) or red categories (Level 1) for at least 2 consecutive years. IHR, International Health Regulations, SP, States Parties.
Food safety
Over the period analysed, food safety was a capacity area with the fewest SPs scoring level 5 (along with risk communication and chemical events). By 2020 more than two-thirds of SPs scored levels 1, 2 or 3, one in four scored level 4 and just one SP scored level 5. Given the multidisciplinary nature of food safety, involving health and many other key sectors such as agriculture and fisheries, SPAR scores for food safety are based on multisectoral collaboration. SPAR scores for levels 2 and 3 focus on multisectoral collaboration and communication capacities within the country, whereas level 4 shifts focus to communication channels at the international level and level 5 involves all processes being regularly assessed, monitored and reviewed. The food safety lower scores indicate challenges in setting up international communication channels and ultimately having processes monitored and evaluated.
Health service provision
The health service provision capacity area consists of three indicators: case management, infection prevention and control (IPC)/water, sanitation and hygiene (WASH) standards and access to essential health services.
For case management of IHR-relevant hazards, more than one-third of SPs had broad access to case management guidelines for priority epidemic-prone diseases available at national, intermediate and local levels (level 2). However, extending this policy to all-hazards was less common with 16 SPs reporting access to all-hazards case management guidelines at national level (level 3) and 10 SPs reporting intermediate/local level access (level 4) in 2020. Regularly reviewing and updating all-hazards case management guidelines (level 5) was implemented in only six SPs by 2020.
For access to essential health services, capacity levels are defined by catchment area and service utilisation. Approximately one in five SPs had less than 50% of catchment areas with essential health services access (level 1). However, the majority of SPs had at least 75% (level 2) or all (level 3) of catchment areas with essential health services access. Improving health service access to high service utilisation was less common with 10 SPs and 8 SPs reporting >2 or >3 outpatient contacts/person/year, respectively (levels 4 and 5) in 2020.
Capacity levels for IPC and chemical and radiation decontamination were low with approximately one in five SPs having IPC/WASH standards for infectious diseases under development (level 1). More than one in three SPs had IPC/WASH standards in place at major hospitals (level 2), but only one in five SPs had IPC/WASH standards in place at all hospitals (level 3). Very few (<10) SPs achieved higher capacity scores reflecting access to decontamination capacity in designated healthcare facilities for chemical events and radiation emergencies. These lower scores are similar to findings in chemical events and radiation emergencies capacity areas.
Risk communication
In 2020, approximately one in three SPs had either ad hoc emergency risk communication mechanisms (level 1) or presence of national level mechanisms (level 2), an improvement from nearly one in two in previous years. In 2018, only 13 SPs had operationalised risk communication mechanisms at the national, intermediate and local level (level 4) yet by 2020 this increased to 23. Only one SP reported tested and updated policies (level 5) throughout the 3-year period. These results indicate challenges in testing, updating and extending risk communication mechanisms beyond national level.
Points of entry
PoE capacity indicators showed improvement with fewer SPs at lower level 1 (PoEs identified for public risk assessment and PoE public health emergency contingency plan in development) and level 2 (some designated PoEs implementing routine core capacities with competent authorities and developed public health emergency contingency plans for biological hazards) in 2020 (47 to 36 SPs). Over the same time, there were more SPs at level 3 (designated PoEs integrated into the national surveillance system for biological hazards and national emergency response plans) increasing from 10 to 18. Similar to the health service provision case management indicator, PoE capacity level 4 requires expansion of capacities and contingency plans to all-hazards events, of which only nine SPs had achieved by 2020. However, improvements were seen in the number of SPs scoring level 5 (routinely evaluated/updated core capacities and all-hazard public health contingency plans at all designated PoEs), from three in 2018 to six in 2020.
Chemical events and radiation emergencies
Both IHR core capacity areas for chemical events and for radiation emergencies have by far the lowest scores of all capacity areas among LICs and LMICs. Over the 3 years, approximately half of all SPs did not report any score (level 0) or reported surveillance mechanisms and resources under development for both chemical events/poisons and radiation emergencies (level 1). One in three SPs achieved level 2 capacity requiring both surveillance capacity for chemical exposures and access to laboratory capacity for identifying/quantifying exposures to key chemicals be available on an ad hoc basis. Few SPs (20 or under) achieved chemical event or radiation emergency capacities above level 2.
Conclusion
We identified six consistently low scoring IHR capacity areas in LICs and LMICs. The majority of SPs had developed some policies and mechanisms at the national level (level 2 or below) with a notable number advancing policies or mechanisms to level 4 or level 5 reflecting expanded coverage for broad utilisation at the local/subnational levels across sectors, addressing all-hazards events and/or enacted mechanisms to test and update policies. However, capacity assessments for chemical and radiation events were consistently low with nearly half of SPs only at the development stage (level 1).
The six low scoring capacity areas identified are crucial to prevent, detect and respond to health emergencies, corresponding to real-world consequences of having low scoring capacities in-country. For example, three-quarters of deaths from foodborne illnesses occur in LICs and LMICs, especially among children.6 Similarly, a survey on essential health service continuity during the COVID-19 pandemic found that 36% of LICs and LMICs reported at least partial disruption to over 75% of services, compared with 4% of high-income countries.7
The success of strengthening IHR capacities largely depends on capacity building in line with contextual factors,2 8 9 such as geographical, social, economic, cultural and political determinants. Understanding these factors is crucial for developing and implementing IHR-relevant policies and mechanisms to enhance health security preparedness. To support this, WHO has developed initiatives to strengthen the global architecture for health emergency prevention, preparedness, response and resilience, which focus on governance and sustainable financing and implementation of health emergency capabilities.10 Additionally, WHO is developing an operational and implementation research agenda for health security preparedness with prioritised research areas. These six low scoring areas may be key for investment, research and capacity strengthening in LICs and LMICs.
Therefore, there is opportunity for the research community to prioritise the search for effective operationalisation methods to support IHR implementation-related policies that consider country-specific context and challenges faced by LICs and LMICs.
Data availability statement
All data used in this analysis are publicly available via the United Nations Sustainable Development Goals portal or WHO GPW13 Triple Billions dashboard.
Ethics statements
Patient consent for publication
Footnotes
Handling editor Seye Abimbola
Twitter @kandelnirmal
Contributors BB, CB and NK developed the concept and drafted the initial version of the manuscript. BB, GNS, CB, RN, RG and NK revised and finalised manuscript. BB and CB conducted the data analysis. All other authors reviewed and contributed to the manuscript.
Funding 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.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.