Independent monitoring and the new pandemic agreement.

Negotiations are underway at the WHO for a legally binding instrument for pandemic prevention, preparedness and response. As seen in the International Health Regulations, however, countries signing up to an agreement is no guarantee of its effective implementation. We, therefore, investigated the potential design features of an accountability framework for the proposed pandemic agreement that could promote countries' compliance with it. We reviewed the governance of a number of international institutions and conducted over 40 interviews with stakeholders and experts to investigate how the pandemic agreement could be governed.We found that enforcement mechanisms are a key feature for promoting the compliance of countries with the obligations they sign up for under international agreements but that they are inconsistently applied. It is difficult to design enforcement mechanisms that successfully avoid inflicting unintended harm and, so, we found that enforcement mechanisms generally rely on soft political levers rather than hard legal ones to promote compliance. Identifying reliable information on states' behaviour with regard to their legal obligations requires using a diverse range of information, including civil society and intergovernmental organisations, and maintaining legal, financial, and political independence.We, therefore, propose that there should be an independent mechanism to monitor states' compliance with and reporting on the pandemic agreement. It would mainly triangulate a diverse range of pre-existing information and have the authority to receive confidential reports and seek further information from states. It would report to a high-level political body to promote compliance with the pandemic agreement.

How an outbreak became a pandemic: a chronological analysis of crucial junctures and international obligations in the early months of the COVID-19 pandemic.

Understanding the spread of SARS-CoV-2, how and when evidence emerged, and the timing of local, national, regional, and global responses is essential to establish how an outbreak became a pandemic and to prepare for future health threats. With that aim, the Independent Panel for Pandemic Preparedness and Response has developed a chronology of events, actions, and recommendations, from December, 2019, when the first cases of COVID-19 were identified in China, to the end of March, 2020, by which time the outbreak had spread extensively worldwide and had been characterised as a pandemic. Datapoints are based on two literature reviews, WHO documents and correspondence, submissions to the Panel, and an expert verification process. The retrospective analysis of the chronology shows a dedicated initial response by WHO and some national governments, but also aspects of the response that could have been quicker, including outbreak notifications under the International Health Regulations (IHR), presumption and confirmation of human-to-human transmission of SARS-CoV-2, declaration of a Public Health Emergency of International Concern, and, most importantly, the public health response of many national governments. The chronology also shows that some countries, largely those with previous experience with similar outbreaks, reacted quickly, even ahead of WHO alerts, and were more successful in initially containing the virus. Mapping actions against IHR obligations, the chronology shows where efficiency and accountability could be improved at local, national, and international levels to more quickly alert and contain health threats in the future. In particular, these improvements include necessary reforms to international law and governance for pandemic preparedness and response, including the IHR and a potential framework convention on pandemic preparedness and response.

Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries.

Health systems resilience is key to learning lessons from country responses to crises such as coronavirus disease 2019 (COVID-19). In this perspective, we review COVID-19 responses in 28 countries using a new health systems resilience framework. Through a combination of literature review, national government submissions and interviews with experts, we conducted a comparative analysis of national responses. We report on domains addressing governance and financing, health workforce, medical products and technologies, public health functions, health service delivery and community engagement to prevent and mitigate the spread of COVID-19. We then synthesize four salient elements that underlie highly effective national responses and offer recommendations toward strengthening health systems resilience globally.

Using the polio programme to deliver primary health care in Nigeria: implementation research.

Objective: To evaluate a project that integrated essential primary health-care services into the oral polio vaccine programme in hard-to-reach, underserved communities in northern Nigeria. Methods: In 2013, Nigeria's polio emergency operation centre adopted a new approach to rapidly raise polio immunity and reduce newborn, child and maternal morbidity and mortality. We identified, trained and equipped eighty-four mobile health teams to provide free vaccination and primary-care services in 3176 hard-to-reach settlements. We conducted cross-sectional surveys of women of childbearing age in households with children younger than 5 years, in 317 randomly selected settlements, pre- and post-intervention (March 2014 and November 2015, respectively). Findings: From June 2014 to September 2015 mobile health teams delivered 2 979 408 doses of oral polio vaccine and dewormed 1 562 640 children younger than 5 years old; performed 676 678 antenatal consultations and treated 1 682 671 illnesses in women and children, including pneumonia, diarrhoea and malaria. The baseline survey found that 758 (19.6%) of 3872 children younger than 5 years had routine immunization cards and 690/3872 (17.8%) were fully immunized for their age. The endline survey found 1757/3575 children (49.1%) with routine immunization cards and 1750 (49.0%) fully immunized. Children vaccinated with 3 or more doses of oral polio vaccine increased from 2133 (55.1%) to 2666 (74.6%). Households' use of mobile health services in the previous 6 months increased from 509/1472 (34.6%) to 2060/2426(84.9%). Conclusion: Integrating routine primary-care services into polio eradication activities in Nigeria resulted in increased coverage for supplemental oral polio vaccine doses and essential maternal, newborn and child health interventions.