“A health risk anywhere is a health risk everywhere.”

“A health risk anywhere is a health risk everywhere.”

-Global Health Security in South Asia[1]

The low- and middle income countries (LMICs) in the South/Southeast Asia are a ‘hot spot’ for emerging and re-emerging infectious diseases[2], and pose a threat to regional health security beside social and economic disruption. The socio-political determinants of health, climate change, pluralistic health system and a large informal sector in these countries complicate the governance and management of infectious diseases in general, and infectious diseases with epidemic/pandemic potential, in particular. This is because ‘health cannot be protected by Ministiries of Health alone’[3]. To address this situation, the revised International Health Regulations [IHR (2005)] aimed to ‘detect, assess, report and respond’ to EIDs. Ultimately, the aim is ‘reduced vulnerability of people to rapidly spreading risks to health, particularly those with great potential to cross international borders[4].

The Joint external Evaluation (JEE) is an external validated system of assessing 19 technical areas required to ‘detect, assess, report and respond’ to health emergencies such as epidemic outbreaks, on a voluntary basis[5]. It is based on ‘peers assessing peers’ and uses a multisectoral ‘One Health approach’ and constitutes the legal framework for global health secuiry. So far, more than 100 countries have completed JEE which show that the countries are poorly prepared to face a major, large scale epidemic disease threat. The gaps are overwhelming in numbers and action plans are yet to be all in place. For example, in the JEE done in 2016, Bangladesh scored poorly (1=no capacity) in areas such as laboratory quality, emergency response operations, linking public health and security authorities, and chemical events[6]. Anecdotal evidence points to improvement in some sectors since 2016 such as laboratory quality, AMR and selected disease surveillance, field epidemiology training etc.

The Human Resources for Health (HRH) at the frontlines of service delivery (e.g., CHWs, para medics, doctors and nurses at PHC facilities, vets and para-vets etc.) are the people who are supposed to deliver the IHR (2005) related health security services as required by the ‘detect, assess, report and respond’ paradigm at the community level, over and above their prime responsibility of delivering health care and health promotion services as part of the Universal Health Coverage (UHC) agenda under the SDGs[7]. However, the additional health security activities at the grassroots require additional training for delivering specialized skills e.g., sentinel surveillance, identification and notification of an outbreak, and putting into action immediate measures for outbreak control etc. 

In a well-coordinated health system,[8] efficiency increases when efforts related to UHC, GHS and health promotion (HP) are integrated at the frontline. This ensures optimum use of available resources and achieve various objectives of the different agendas simultaneously, e.g., UHC, HS and HP[9]. Currently, there is a shortage of HRH in these countries especially at the frontlines, due to inequitable distribution of available HRH across the rural and urban areas, and problems associated with inappropriate skills-mix[10]. Whatever is available, is plagued with low levels of retention and frequent absenteeism. For example, in Bangladesh, existing policies do not specify how this health security activities can be conducted in an efficient and effective manner with the available resources (GHS roadmap, 2015[11]; HNPSIP, 2016[12]; SBCC, 2016[13]). In turn, the service delivery also suffers as fewer people are available to work on many activities for each of the agendas. The scenario is presumed to be pretty similar in other LMICs as well.

[excerpts from a forthcoming proposal] 

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[1] Johns Hopkins Center for Health Security. Global Health Security in South Asia. Report from the July 10, 2018, meeting in Washington, DC, September 2018

[2] R.J. Coker, et al. 2011. Emerging Infectious Diseases in Southeast Asia: Regional Challenges to Control. Lancet. 377, 599–609.

[3] Shahpar C, Lee CT, Wilkason C, et al. Protecting the world from infectious disease threats: now or never. BMJ Global Health2019;4:e001885. doi:10.1136/bmjgh-2019-001885

[4] Lancet Commission on Synergy. Contribution of Health Security to UHC. PP presented at the Commission meeting.

[5] Shahpar C, Lee CT, Wilkason C, et al. Protecting the world from infectious disease threats: now or never. BMJ Global Health 2019;4:e001885. doi:10.1136/bmjgh-2019-001885

[6] https://apps.who.int/iris/bitstream/handle/10665/254275/WHO-HSE-GCR-2016.23-eng.pdf?sequence=1 (Data for 2016; no follow-up evaluation reported)

[7] https://sustainabledevelopment.un.org/sdgs

[8] https://www.who.int/whr/2000/en/

[9] Wenham C, Katz R, Birungi C, et al. Global health security and universal health coverage: from a marriage of convenience

to a strategic, effective partnership. BMJ Glob Health 2019;4:e001145. doi:10.1136/bmjgh-2018-001145

[10] Ahmed et al. Human Resources for Health 2011, 9:3

http://www.human-resources-health.com/content/9/1/3

[11] https://www.ghsagenda.org/docs/default-source/ghsa-roadmaps/ghsa-bangladesh-roadmap.pdf

[12] HEALTH, NUTRITION AND POPULATION STRATEGIC INVESTMENT PLAN (HNPSIP) 2016 – 21

“Better Health for a Prosperous Society” APRIL 2016. MoHFW, GoB.

[13] Comprehensive Social and Behavioural Change Communication Strategy. 2016. MoHFW, GoB.