How prepared is the world? Identifying weaknesses in existing assessment frameworks for global health security through a One Health approach.

The COVID-19 pandemic has exposed faults in the way we assess preparedness and response capacities for public health emergencies. Existing frameworks are limited in scope, and do not sufficiently consider complex social, economic, political, regulatory, and ecological factors. One Health, through its focus on the links among humans, animals, and ecosystems, is a valuable approach through which existing assessment frameworks can be analysed and new ways forward proposed. Although in the past few years advances have been made in assessment tools such as the International Health Regulations Joint External Evaluation, a rapid and radical increase in ambition is required. To sufficiently account for the range of complex systems in which health emergencies occur, assessments should consider how problems are defined across stakeholders and the wider sociopolitical environments in which structures and institutions operate. Current frameworks do little to consider anthropogenic factors in disease emergence or address the full array of health security hazards across the social-ecological system. A complex and interdependent set of challenges threaten human, animal, and ecosystem health, and we cannot afford to overlook important contextual factors, or the determinants of these shared threats. Health security assessment frameworks should therefore ensure that the process undertaken to prioritise and build capacity adheres to core One Health principles and that interventions and outcomes are assessed in terms of added value, trade-offs, and cobenefits across human, animal, and environmental health systems.

Improving National Intelligence for Public Health Preparedness: a methodological approach to finding local multi-sector indicators for health security.

The COVID-19 epidemic is the latest evidence of critical gaps in our collective ability to monitor country-level preparedness for health emergencies. The global frameworks that exist to strengthen core public health capacities lack coverage of several preparedness domains and do not provide mechanisms to interface with local intelligence. We designed and piloted a process, in collaboration with three National Public Health Institutes (NPHIs) in Ethiopia, Nigeria and Pakistan, to identify potential preparedness indicators that exist in a myriad of frameworks and tools in varying local institutions. Following a desk-based systematic search and expert consultations, indicators were extracted from existing national and subnational health security-relevant frameworks and prioritised in a multi-stakeholder two-round Delphi process. Eighty-six indicators in Ethiopia, 87 indicators in Nigeria and 51 indicators in Pakistan were assessed to be valid, relevant and feasible. From these, 14-16 indicators were prioritised in each of the three countries for consideration in monitoring and evaluation tools. Priority indicators consistently included private sector metrics, subnational capacities, availability and capacity for electronic surveillance, measures of timeliness for routine reporting, data quality scores and data related to internally displaced persons and returnees. NPHIs play an increasingly central role in health security and must have access to data needed to identify and respond rapidly to public health threats. Collecting and collating local sources of information may prove essential to addressing gaps; it is a necessary step towards improving preparedness and strengthening international health regulations compliance.

Economic impact of Ebola virus disease outbreak on an extractive firm: a case study.

Purpose: The recent Ebola virus disease (EVD) epidemic was one of the most severe public health emergencies in modern times. The economic impact of epidemics has mostly been analysed at the macroeconomic level. Conversely, we aimed to estimate the economic costs of preventive measures of the epidemic to an extractive firm, ArcelorMittal (AM), using data in the epidemic region from March 2014 to December 2015. AM is the world's largest steel producer and is particularly important in West Africa, where the extractive industry is economically crucial. Methods: Qualitative methods, in-depth interviews (IDIs) and focus group discussions (FGDs), were used to investigate the events and channels of impact of the epidemic on the firm, as perceived by employees and contractors. Quantitative data regarding these costs were also collected. Retrospective cost analysis estimated the actual cost of preventive methods adopted. Results: Most respondents indicated the largest cost impact was suspension of the Phase II expansion, a series of projects designed to increase iron ore production in Liberia. The next largest cost was the preventive measures adopted to counter disease spread. Total costs incurred for adopting preventive measures were USD 10.58-11.11 million. The overall direct costs of preventive measures adopted within the fence, meaning within the physical boundary of the firm's sites, shared 30-31% of the total costs incurred. The share of external donations supporting humanitarian response was 11-12% of the total costs, followed by 7-12% of relational costs. Conclusions: The firm's response during the EVD epidemic focussed on its employees and operations, which was later expanded to the wider community and then in supporting the international humanitarian response.

Methodological gaps and opportunities for studying multisectoral collaboration for health in low- and middle-income countries.

The current body of research into multisectoral collaborations (MSCs) for health raises more questions than it answers, both in terms of how to implement MSCs and how to study them. This article reflects on current methodological gaps and opportunities for advancing MSC research, based on a targeted review of existing literature and qualitative input from researchers and practitioners at the 2018 Health Systems Research (HSR) Symposium in Liverpool. Through framework analysis of 205 MSC research papers referenced in a separately published MSC 'overview of reviews' paper, this article identifies six broad MSC question domains ('meta questions') and applies content analysis to estimate the relative frequency with which these meta questions and the research method(s) used to answer them are present in the literature. Results highlight a preponderance of research exploring MSC implementation using case study methods, which, in aggregate, does not seem to adequately meet policymakers' and practitioners' needs for generalizable or transferable insights. The content analysis is complemented by qualitative insights from HSR Symposium participants and the authors' own experience to identify six key methodological gaps in research on MSC for health. For each of these gaps, we propose areas in which we believe there are opportunities for methodological development and innovation to help advance this field of study, including: better understanding the role of power dynamics in shaping MSCs; development of a classification framework (or frameworks) of governance arrangements; exploring divergence of perspective and experience among MSC partners; identifying or generating theoretical frameworks for MSC that work across sectors and disciplines; developing intermediate indicators of collaboration; and increasing transferability of insights to other contexts. Collaboration with researchers outside of the health sector will enhance efforts in each of these areas, as will the establishment and strengthening of pluralistic MSC evidence networks also involving policymakers and practitioners.

Is the current surge in political and financial attention to One Health solidifying or splintering the movement?

INTRODUCTION: The global health field has witnessed the rise, short-term persistence and fall of several movements. One Health, which addresses links between human, animal and environmental health, is currently experiencing a surge in political and financial attention, but there are well-documented barriers to collaboration between stakeholders from different sectors. We examined how stakeholder dynamics and approaches to operationalising One Health have evolved further to recent political and financial support for One Health. METHODS: We conducted a mixed methods study, first by qualitatively investigating views of 25 major policymakers and funders of One Health programmes about factors supporting or impeding systemic changes to strengthen the One Health movement. We then triangulated these findings with a quantitative analysis of the current operations of 100 global One Health Networks. RESULTS: We found that recent attention to One Health at high-level political fora has increased power struggles between dominant human and animal health stakeholders, in a context where investment in collaboration building skills is lacking. The injection of funding to support One Health initiatives has been accompanied by a rise in organisations conducting diverse activities under the One Health umbrella, with stakeholders shifting operationalisation in directions most aligned with their own interests, thereby splintering and weakening the movement. While international attention to antimicrobial resistance was identified as a unique opportunity to strengthen the One Health movement, there is a risk that this will further drive a siloed, disease-specific approach and that structural changes required for wider collaboration will be neglected. CONCLUSION: Our analysis indicated several opportunities to capitalise on the current growth in One Health initiatives and funding. In particular, evidence from better monitoring and evaluation of ongoing activities could support the case for future funding and allow development of more precise guidelines on best practices.

Pathogens, prejudice, and politics: the role of the global health community in the European refugee crisis.

Involuntary migration is a crucially important global challenge from an economic, social, and public health perspective. The number of displaced people reached an unprecedented level in 2015, at a total of 60 million worldwide, with more than 1 million crossing into Europe in the past year alone. Migrants and refugees are often perceived to carry a higher load of infectious diseases, despite no systematic association. We propose three important contributions that the global health community can make to help address infectious disease risks and global health inequalities worldwide, with a particular focus on the refugee crisis in Europe. First, policy decisions should be based on a sound evidence base regarding health risks and burdens to health systems, rather than prejudice or unfounded fears. Second, for incoming refugees, we must focus on building inclusive, cost-effective health services to promote collective health security. Finally, alongside protracted conflicts, widening of health and socioeconomic inequalities between high-income and lower-income countries should be acknowledged as major drivers for the global refugee crisis, and fully considered in planning long-term solutions.

The annual Hajj pilgrimage-minimizing the risk of ill health in pilgrims from Europe and opportunity for driving the best prevention and health promotion guidelines.

Mass gatherings at religious events can pose major public health challenges, particularly the transmission of infectious diseases. Every year the Kingdom of Saudi Arabia (KSA) hosts the Hajj pilgrimage, the largest gathering held on an annual basis where over 2 million people come to KSA from over 180 countries. Living together in crowded conditions exposes the pilgrims and the local population to a range infectious diseases. Respiratory and gastrointestinal tract bacterial and viral infections can spread rapidly and affect attendees of mass gatherings. Lethal infectious disease outbreaks were common during Hajj in the 19th and 20th centuries although they have now been controlled to a great extent by the huge investments made by the KSA into public health prevention and surveillance programs. The KSA provides regular updated Hajj travel advice and health regulations through international public health agencies such as the WHO, Public Health England, the Centers for Disease Control and Prevention, and Hajj travel agencies. During the Hajj, an additional 25 000 health workers are deployed; there are eight hospitals in Makkah and Mina complete with state-of-the-art surgical wards and intensive care units made specifically available for pilgrims. All medical facilities offer high quality of care, and services are offered free to Hajj pilgrims to ensure the risks of ill health to all pilgrims and KSA residents are minimal. A summary of the key health issues that arise in pilgrims from Europe during Hajj and of the KSA Hajj guidelines, together with other factors that may play a role in reducing the risks to pilgrims and to wider global health security, is provided herein.

Exploring the evidence base for national and regional policy interventions to combat resistance.

The effectiveness of existing policies to control antimicrobial resistance is not yet fully understood. A strengthened evidence base is needed to inform effective policy interventions across countries with different income levels and the human health and animal sectors. We examine three policy domains-responsible use, surveillance, and infection prevention and control-and consider which will be the most effective at national and regional levels. Many complexities exist in the implementation of such policies across sectors and in varying political and regulatory environments. Therefore, we make recommendations for policy action, calling for comprehensive policy assessments, using standardised frameworks, of cost-effectiveness and generalisability. Such assessments are especially important in low-income and middle-income countries, and in the animal and environmental sectors. We also advocate a One Health approach that will enable the development of sensitive policies, accommodating the needs of each sector involved, and addressing concerns of specific countries and regions.

Integrating health into disaster risk reduction strategies: key considerations for success.

The human and financial costs of disasters are vast. In 2011, disasters were estimated to have cost $378 billion worldwide; disasters have affected 64% of the world's population since 1992. Consequently, disaster risk reduction strategies have become increasingly prominent on national and international policy agendas. However, the function of health in disaster risk reduction strategies often has been restricted to emergency response. To mitigate the effect of disasters on social and health development goals (such as risk reduction Millennium Development Goals) and increase resilience among at-risk populations, disaster strategies should assign the health sector a more all-encompassing, proactive role. We discuss proposed methods and concepts for mainstreaming health in disaster risk reduction and consider barriers faced by the health sector in this field.

Mapping the Gypsy Traveller community in England: what we know about their health service provision and childhood immunization uptake.

BACKGROUND: A series of reports over the last two decades have concluded that the overall health status of UK Gypsy Traveller Community is very poor when compared with the general population and relatively poor in comparison with other disadvantaged groups. Despite a government commitment to reducing health inequalities, differences in health outcomes and in healthcare access and service provision have persisted. METHODS: In order to understand immunization services for Gypsy Travellers, the Health Protection Agency conducted a survey and mapping exercise of Primary Care Trusts in England to ascertain what is known about local Gypsy Traveller populations, estimate immunizations rates and describe current services to increase immunization as well as to address wider health issues. RESULTS: Despite improvements in the provision of specialist services for the Gypsy Traveller communities in England, there still remains a considerable number of areas where knowledge of population numbers is poor, service provision is not based on need and the uptake of immunization is low or not known. CONCLUSION: There is an ongoing need to improve knowledge of population numbers and the provision of and access to services that are culturally sensitive and responsive to the needs of Gypsy Traveller communities. Whilst we have focused on describing immunization uptake, immunization services are only one component of a wider strategy for improving the health of Gypsy Travellers through effective health and social care interventions.

Conducting rapid health needs assessments in the cluster era: experience from the Pakistan flood.

Due to its unprecedented scale, the Pakistan flood disaster tested the limits of disaster management and coordination. Under the leadership of the World Health Organization, the Global Health Cluster system for coordinating activities improved collaboration and efficiency in conducting rapid needs assessments. However, the involvement of non-Cluster members was lacking, and information on existing service provision was not collected adequately. The present rapid health needs assessment process under the Cluster system will be discussed, using the recent floods in Pakistan as an example.