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 Table of Contents  
PERSPECTIVE
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 5-14

Turning commitments into actions: perspectives on emergency preparedness in South-East Asia


World Health Organization Health Emergencies Programme, World Health Organization Regional Office for South-East Asia, New Delhi, India

Date of Web Publication26-Apr-2020

Correspondence Address:
Dr Roderico H Ofrin
World Health Organization Health Emergencies Programme, World Health Organization Regional Office for South-East Asia, New Delhi
India
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DOI: 10.4103/2224-3151.282989

PMID: 32341215

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  Abstract 


Emergency preparedness is a continuous process in which risk and vulnerability assessments, planning and implementation, funding, partnerships and political commitment at all levels must be sustained and acted upon. It relates to health systems strengthening, disaster risk reduction and operational readiness to respond to emergencies. Strategic interventions to strengthen the capacities of countries in the World Health Organization (WHO) South-East Asia Region for emergency preparedness and response began in 2005. Efforts accelerated from 2014 when emergency risk management was identified as one of the regional flagship priority programmes following the pragmatic approach “sustain, accelerate and innovate”. Despite increased attention and some progress on risk management, the existing capacities to respond to health emergencies are inadequate in the face of prevailing and increasing threats posed by multiple hazards, including climate change and emerging and re-emerging diseases. The setting up of a “preparedness stream” under the South-East Asia Regional Health Emergency Fund in July 2016 was an important milestone. The endorsement of the Five-year regional strategic plan to strengthen public health preparedness and response – 2019–2023 by Member States was another step forward. Furthermore, ministerial-level commitment, in the form of the Delhi Declaration on Emergency Preparedness, adopted in September 2019 in the 72nd session of the WHO Regional Committee for South-East Asia, is in place to facilitate Member States to invest resources in the protection and safety of people and systems and in overall emergency risk management through national action plans for health security. It is essential now to turn these commitments into actions to strengthen emergency preparedness in countries of the region.

Keywords: Delhi Declaration, emergency preparedness, regional strategies, South-East Asia


How to cite this article:
Ofrin RH, Bhola AK, Buddha N. Turning commitments into actions: perspectives on emergency preparedness in South-East Asia. WHO South-East Asia J Public Health 2020;9:5-14

How to cite this URL:
Ofrin RH, Bhola AK, Buddha N. Turning commitments into actions: perspectives on emergency preparedness in South-East Asia. WHO South-East Asia J Public Health [serial online] 2020 [cited 2020 Jul 12];9:5-14. Available from: http://www.who-seajph.org/text.asp?2020/9/1/5/282989




  Background Top


The World Health Organization (WHO) South-East Asia Region is vulnerable to a varied range of natural hazards and human-induced disasters; it also has a high burden of outbreaks of common diseases and emerging and re-emerging diseases, including zoonoses. People in this region are frequently exposed to seasonal floods, landslides, tsunamis, droughts, earthquakes, volcanic eruptions and extreme weather conditions.[1] As noted in the World disasters report 2018, during 2008–2017, 79.8% of people affected by disasters lived in Asia and 45.4% of estimated damages resulted from disasters in Asia.[2]

Pathogens associated with recent outbreaks in countries of the region include avian influenza A(H5N1) and A(H9N2), influenza A(H1N1)pdm09, Zika virus, Middle East respiratory syndrome coronavirus, Nipah virus and Crimean Congo haemorrhagic fever virus.[1] Hazards, outbreaks and resultant health emergencies are frequent,[3] as set out in [Annex Table 1], which clearly illustrates the high degree of vulnerability and exposure of people of the region to prevailing risks and hazards. Hardly a year passes without an emergency in the region. The drivers of risk are growing rapidly in south-east Asia. Unplanned urbanization, inequitable and risk-uninformed development planning, close human–animal and wildlife habitations, variations in climatic conditions and newly emerging environmental health emergencies such as air pollution are wake-up calls indicating that urgent corrective measures are required to restore the public health ecology.



“Emergency preparedness” is defined as the “capability of the public health and health-care systems, communities, and individuals, to prevent, protect against, quickly respond to, and recover from health emergencies, particularly those whose scale, timing, or unpredictability threatens to overwhelm routine capabilities”.[4] Emergency preparedness is a continuous process in which risk and vulnerability assessments, planning and implementation, funding, partnerships and political commitment at all levels must be sustained. It relies on all stakeholders working together effectively to plan, invest in and implement priority actions. It bridges the gaps between health systems strengthening, disaster risk reduction and operational readiness to respond to emergencies.


  Overview of emergency preparedness in the region Top


The Indian Ocean tsunami in 2004 alerted the whole world, and countries in South-East Asia in particular, to the need to reassess approaches to planning, designing and delivering health-care services and public health systems. It was recognized that the prevailing risks, hazards and vulnerabilities of people and systems could no longer be considered in isolation and only in the aftermath of a disaster but instead needed to be addressed and integrated into health systems and services. Since then, significant work has been done to strengthen emergency preparedness in the region; key strategic interventions are shown in [Figure 1].
Figure 1. Key strategic interventions for emergency preparedness in the WHO South-East Asia Region, 2004–2019

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The WHO Regional Office for South-East Asia began its efforts to develop comprehensive preparedness plans for each country of the region in 2006, focusing first on public health workforce development.[5] Guidance on benchmarks, standards and indicators for emergency preparedness and response were produced in 2007 to assist countries in assessing their capacities to respond to health emergencies.[6] A key milestone was the establishment of the South-East Asia Regional Health Emergency Fund through Regional Committee resolution SEA/RC/60/R7 in 2007.[7] The fund became effective in January 2008 and is designed to provide immediate financial support for the first 3 months in the aftermath of an emergency in countries of the region. Through the WHO country offices, the countries can obtain financial support from the fund within 24 hours of an emergency.

In 2011, the regional office decided to focus on capacity-building and training; addressing water and sanitation and nutrition in emergencies; vulnerability assessments; and available technologies. This work synergized efforts on risk identification, mapping of health risks and multi-hazards, use of information technology and innovations in risk mitigation. The focused approach accelerated capacity-building in the health sector and related sectors for strengthening preparedness for and response to acute events.

Sound risk management is essential for safeguarding development and implementing local, national, regional and global strategies in the health sector and other sectors,[8] including the Sustainable Development Goals,[9] the Sendai Framework for Disaster Risk Reduction 2015–2030,[10] the International Health Regulations 2005 (IHR)[11] and the Paris Agreement on climate change.[12] The lack of preparedness of health systems in low- and middle-income countries revealed in 2014–2015 during the Ebola outbreaks in Guinea, Liberia, Nigeria and Sierra Leone led to structural and operational reform in WHO’s emergency work. Lessons were learnt from these events, and emergency risk management was identified as one of the flagship priority programmes of the WHO South-East Asia Region; these programmes were established in 2014 to sustain, accelerate and innovate approaches to regional priority areas.[13] The overarching strategy has been to sustain ongoing efforts and step up implementation of such efforts, while fostering innovation to protect the people of countries of the region from the adverse impacts of hazards and emergencies.

The global WHO Health Emergencies Programme was formulated and became active in August 2016 to work with Member States in all phases of emergencies, from risk reduction and preparedness to response and recovery.[14],[15] The Global Preparedness Monitoring Board (GPMB) was established in 2017 following recommendations made by the United Nations Secretary-General’s Global Health Crises Task Force in the same year.[25] The GPMB comprises political leaders, agency principals and leading international experts. It provides independent and comprehensive appraisals for policy-makers and the world of progress towards increased preparedness and response capacity for disease outbreaks and other emergencies with health consequences.

Following the setting up of the global programme, the WHO Health Emergencies Programme was also established in the Regional Office for South-East Asia to support the strengthening of the emergency preparedness and response capacity of Member States.

Identifying risks

For a country or region to be prepared to minimize the impact of any hazard or emergency, its systems, plans and people must be fully cognizant of prevailing risks, hazards and vulnerabilities, and it must have integrated risk-informed planning into all development processes. To enable evidence-informed planning, a comprehensive analysis was undertaken, resulting in 2017 in the publication of Roots for resilience: a health emergency regional risk profile of the South-East Asia Region.[1] This was an important landmark on the path to strengthening emergency preparedness and formed a baseline for mapping, monitoring, planning and reducing existing and potential risks, hazards and vulnerabilities. The risk profile methodology included an assessment of five priority syndromes, each represented by a selected disease, for all 11 countries of the region. These were (i) severe acute respiratory illness, represented by Middle East respiratory syndrome; (ii) acute watery diarrhoea, represented by cholera; (iii) acute haemorrhagic fever, represented by Crimean Congo haemorrhagic fever; (iv) acute encephalitis syndrome, represented by Japanese encephalitis; and (v) acute febrile illness with rash, represented by Zika virus disease. The risk assessment showed the region to be homogeneously vulnerable to all five threats. With respect to natural hazards, the analysis indicated that the countries of the region share a range of risks, with common vulnerabilities and capacities. The only differences lie in the types of risk and their magnitude, based on geographical and geological parameters. The results of the analyses done for the Roots for resilience report clearly showed that existing capacities in the WHO South-East Asia Region did not match the prevailing and ever-increasing threats.[1]

Investing in people and systems for risk management

Improved understanding of risks, hazards, vulnerabilities and the increasing exposure of populations in the region has facilitated investments in capacity-building in relation to IHR compliance. The entry into force of the IHR in 2007 marked a new era of international cooperation for the management of international public health events and emergencies. Since 2016, States Parties have been checking their progress on IHR compliance through mandatory self-assessment using the State Party annual reporting tool,[26] and three voluntary mechanisms: simulation exercises,[27] after action reviews[28] and joint external evaluations.[29] All countries of the region have complied with State Party annual reporting, including with regard to use of the electronic reporting tool. The results to date show that considerable progress has been achieved in the areas of legislation, coordination, surveillance, response, risk communication, laboratory systems and zoonoses (see [Figure 2]). However, there is constrained capacity of human resources in the IHR national focal points (NFPs) across the region, especially in the areas of epidemiology, vector control, infection control, travel medicine, risk communication, emerging and re-emerging diseases, and management of mass gatherings and points of entry (i.e. international airports, ports, ground crossings). According to the joint external evaluations of IHR capacities conducted in eight countries of the region, the existing capacities in relation to biological, chemical or radionuclear threats, control of disease transmission at ground crossings, biosafety and biosecurity in laboratories, antimicrobial resistance and management of cross-border conflict situations in the region are limited (see [Figure 2]).[30],[31]
Figure 2:

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Five countries of the region have conducted after action reviews, and Indonesia and Nepal have conducted simulation exercises involving various stakeholders including WHO. A regional training workshop in September 2019 on how to design and conduct simulation exercises and after action reviews imparted required knowledge and skills to the participants, who included representatives of the Member States and WHO country offices.

The region has acted upon its concerns about climate change and resultant extreme weather conditions detrimental to health. In 2017, the WHO Regional Committee passed resolution SEA/RC70/R1 endorsing the Malé Declaration and the Framework for action in building health systems resilience to climate change in South-East Asia Region, 2017–2022.[17],[18]

Damage to health-care infrastructure, physical injuries to individuals and loss of or separation from family members may result in discontinuity of treatment and care of patients with noncommunicable diseases (NCDs). To ensure continuity of NCD care in emergencies, a comprehensive guideline, Integration of NCD care in emergency response and preparedness, was developed in 2018.[21] To further ensure continuity of treatment and disaster preparedness in hospitals, an innovative Hospital Safety Index plus mobile application was introduced in 25 hub hospital networks in and around Kathmandu, Nepal, in 2019, and training was provided to staff. Bhutan, India, Indonesia and Thailand have also introduced initiatives to assess health facilities on their preparedness for multiple hazards.

Implementing plans and initiatives

The prioritization of emergency risk management under the regional flagship priority programme following the “sustain, accelerate and innovate” approach since 2014 has driven the development and implementation of various plans and initiatives with a focus on emergency preparedness (see [Table 1]). Various examples of prioritizing emergency preparedness by the Member States in the region are provided in [Box 1].
Table 1. Flagship priority programme on emergency risk management: sustain, accelerate and innovate

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A major milestone on emergency preparedness was the development of two regional strategic plans in consultation with the Member States and the endorsement of these plans by the WHO Regional Committee in 2019. The Committee then approved and launched two key regional strategies strategies to guide Member States and for them to adapt.

The Five-year regional strategic plan to strengthen public health preparedness and response – 2019–2023[22] was prepared based on a situational analysis of progress on IHR implementation in the region, gaps and opportunities identified from the eight joint external evaluations done during 2016–2018, and a regional consultation with the IHR NFPs and partners in New Delhi in March 2019. It is aligned with the global strategic plan and one of the three strategic priorities – 1 billion more people better protected from emergencies – of WHO’s Thirteenth general programme of work 2019–2023.[36] It is also in line with the Bangkok principles for the implementation of the health aspects of the Sendai framework for disaster risk reduction 2015–2023 of March 2016.[37] It aims to strengthen the capacities of IHR NFPs on public health preparedness and response through refocusing on identified gaps, developing robust monitoring mechanisms, and improving networking and collaboration.

The Risk communication strategy for public health emergencies in the WHO South-East Asia Region[23] aims to ensure that each Member State builds and uses a multilevel, multisectoral and multifaceted risk communication plan to enable individuals, families and communities to make informed decisions to mitigate the effects of emergencies and take protective and preventive actions. It lays down a framework for Member States and WHO to strengthen critical capacity in five key areas: risk communication systems, internal and partner coordination, public communication, community engagement, and public preparedness, risky behaviour and misinformation.

Interlinking sectors and networks

In order to strengthen intersectoral synergies and partnerships and collaboration among public and private stakeholders and operational partners for emergency preparedness and response, the Regional framework on operational partnership for emergency response (South-East Asia Region)[3] was developed in 2017; it guides Member States, WHO country offices and partners on building operational partnerships in pre-emergency, emergency and post-emergency phases. Efforts to develop, foster and strengthen partnerships and networks through the engagement of emergency medical teams,[38] the Global Outbreak Alert and Response Network,[39] the Standby Partnership,[40] the Inter-Agency Standing Committee Health Cluster[41] and private stakeholders are being pursued continuously. In September 2018, the WHO Regional Committee for South-East Asia passed resolution SEA/RC71/R5 on strengthening national and international emergency medical teams in the region.[20]

The establishment of the regional knowledge network of IHR NFPs and domain experts created an innovative online platform for enabling peer-to-peer learning through an IHR-focused community of practice. It provides opportunities for exchanging ideas, consultation and discussion on IHR notifications and problematic issues in an informal online environment.

Efforts to build partnerships and collaborations have not been limited to the WHO South-East Asia Region and have been expanded through the Asia Pacific strategy for emerging diseases and public health emergencies (APSED III) in relation to all hazards.[19]

Challenges

Strengthening emergency preparedness is not limited to risk identification, risk mapping and development of strategic plans. It requires time and resources to make any population, system, country or region resilient to prevailing risks and threats. The following key challenges are indicative of the constraints on this regional flagship priority:

  • the need for repetitive spending by Member States and partners on emergencies of a seasonal nature (e.g. floods, cyclones, landslides) and the danger of not investing enough to prevent or mitigate prevailing risks;
  • lack of investment in addressing the drivers of risks, all-hazard emergency preparedness, and building back better because:


  • ○ there are competing priorities within and outside the health sector;

    ○ investors are not always rewarded with results and greater visibility within a limited time period;

  • lack of resilience of health systems at subnational and local levels;
  • lack of risk-informed development planning for the long term at national and regional levels;
  • lack of interest from private sector stakeholders in building resilient systems, despite the existence of laws on corporate social responsibility;
  • inadequate budgetary allocation for and domestic funding of the health sector;
  • innovative financial instruments for financing preparedness not yet fully explored;
  • limited use of technology for preparedness and response in the health sector.


Financing of health emergency preparedness has been a key challenge. To address it, an important strategic decision was taken in 2016 to emben emergency preparedness in the region. Regional Committee resolution SEA/RC69/R6 endorsed the expansion of the mandate of the South-East Asia Regional Health Emergency Fund to include an additional financing stream focused on preparedness.[16] It needs further financial support from donors to help and assist countries in investing more in disaster risk reduction (e.g. in hospital safety assessments), preparedness and operational readiness. During the 72nd session of the Regional Committee in September 2019, the Union Minister of Health and Family Welfare, Government of India, pledged a contribution of US$ 200 000 to the preparedness stream for strengthening disaster and emergency preparedness.[42] The WHO Regional Office for South-East Asia has also developed a resource mobilization strategy and orientation manual to accelerate its fundraising.[43]

Despite all the progress on emergency risk management and strategic interventions to boost emergency preparedness, the countries’ existing capacities to respond to health emergencies do not seem to be adequate in the regional context of high burden of disease, frequent disease outbreaks, and a growing number of risks and hazards, as illustrated in Annex Table 1. This raises the question “Are we adequately prepared to withstand any unexpected emergency or disaster?”


  Delhi Declaration on Emergency Preparedness Top


A continued push following the “sustain, accelerate and innovate” approach on emergency risk management under the regional flagship priority programme since 2014 has sustained a focus on strengthening emergency preparedness in the region. This culminated in the adoption of the ministerial-level Delhi Declaration on Emergency Preparedness at the WHO Regional Committee for South-East Asia meeting in 2019.[24] It reflects the strong political commitment of the Member States to increase investment in building resilient health systems, implementing national action plans for health security, and strengthening networks and intersectoral coordination mechanisms following the One Health approach.

Various strategies, plans and political commitments have been made since 2006. Now it is time to convert these commitments into actions. Generating evidence, guidelines, strategic plans and political declarations without commensurate actions is not only irresponsible public health practice but also amounts to negligence with regard to the safety and protection of populations of this region amid known and unknown health risks and threats. Emergency preparedness is a long-term investment the results of which are visible at times of disaster or emergency when loss of lives and damage to critical infrastructure are seen to be minimized.


  Conclusions Top


Identification, mapping and mitigation measures in relation to risks, hazards and vulnerabilities facilitate the strengthening of emergency preparedness and operational readiness. The region, having a high degree of vulnerability and significant exposure to natural hazards, disease outbreaks and human-induced disasters and emergencies, has since 2005 gradually strategically shifted from investing in emergency response to investing in risk reduction and emergency preparedness.

There has been an increase in IHR core capacities. However, the IHR NFPs across the region need to improve capacity in certain areas with more impetus and investments: emergency preparedness; readiness to deal with any unexpected chemical or radionuclear emergency; enhancing biosafety and biosecurity in laboratory networks to curb increasing antimicrobial resistance due to weak medical countermeasures and delayed personnel deployment; and improving prevention and control of disease transmission at points of entry.[44]

Strong political commitment and budgetary allocations for investment in emergency preparedness and disaster risk reduction are needed to sustain the health development gains. Member States should prioritize national action plans for health security and mobilize domestic funding and support from partners to implement the plans. Innovative financial mechanisms need to be tapped to raise funds from donors and bilateral agencies in the region to finance emergency preparedness and risk reduction.

Member States must fulfil their commitment to the four I’s of the Delhi Declaration: (i) identify risks, (ii) invest in people and building resilient systems, (iii) implement plans and (iv) interlink human, animal, wildlife and environmental sectors, following an ecological public health approach and strengthening networks. Emergency preparedness is continuous work and a top priority for achieving comprehensive development and health security in the region and the world.

Source of support: None.

Conflict of interest: None declared.

Authorship: RHO conceptualized the design of the paper and provided overall guidance, AKB prepared the first draft, NB provided substantial input, and RHO, AKB and NB together worked on versions of the draft and finalized the manuscript.



 
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