WHO South-East Asia Journal of Public Health
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   Table of Contents - Current issue
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April 2020
Volume 9 | Issue 1
Page Nos. 1-91

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EDITORIAL  

Quo vadis after COVID-19: a new path for global emergency preparedness? Highly accessed article p. 1
Poonam Khetrapal Singh, Roderico H Ofrin
DOI:10.4103/2224-3151.282988  PMID:32341214
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PERSPECTIVE Top

Turning commitments into actions: perspectives on emergency preparedness in South-East Asia p. 5
Roderico H Ofrin, Anil K Bhola, Nilesh Buddha
DOI:10.4103/2224-3151.282989  PMID:32341215
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.
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Strengthening risk communication systems for public health emergencies in the WHO South-East Asia Region p. 15
Roderico H Ofrin, Nilesh Buddha, Maung Maung Htike, Anil K Bhola, Supriya Bezbaruah
DOI:10.4103/2224-3151.282990  PMID:32341216
Risk communication and community engagement are critical aspects of public health emergency preparedness and response and therefore one of the eight original core capacities of the International Health Regulations (2005). Joint external evaluations in eight out of eleven countries of the World Health Organization South-East Asia Region reveal that there is considerable variation in risk communication capacities among countries. Of the five areas evaluated – risk communication systems, internal and partner coordination, public communication, community engagement and listening, and risky behaviour and misinformation – the strongest areas, across the region, are partner coordination and community engagement, while risk communication systems is the weakest area and needs further strengthening. For strong and sustainable risk communication for public health emergencies in the WHO South East Asia Region, institutionalized capacity-building supported by increased budgetary allocations to this area is needed. There is a strong need for advocacy to and sensitization of key policy-makers and decision-makers at country level regarding the importance and advantages of being prepared on risk communication plans and systems.
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Operationalization of One Health and tripartite collaboration in the Asia-Pacific region p. 21
Gyanendra Gongal, Roderico H Ofrin, Katinka de Balogh, Yooni Oh, Hirofumi Kugita, Kinzang Dukpa
DOI:10.4103/2224-3151.282991  PMID:32341217
One Health refers to the collaborative efforts of multiple disciplines working locally, nationally and globally to attain optimal health for people, animals and our environment. The One Health approach is increasingly popular in the context of growing threats from emerging zoonoses, antimicrobial resistance and climate change. The Food and Agriculture Organization of the United Nations, World Organisation for Animal Health and World Health Organization have been working together in the wake of the avian influenza crisis in the Asia-Pacific region to provide strong leadership to endorse the One Health concept and promote interagency and intersectoral collaboration. The programme on highly pathogenic emerging diseases in Asia (2009–2014) led to the establishment of a regional tripartite coordination mechanism in the Asia-Pacific region to support collaboration between the animal and human health sectors. The remit of this mechanism has expanded to include other priority One Health challenges, such as antimicrobial resistance and food safety. The mechanism has helped to organize eight Asia-Pacific workshops on multisectoral collaboration for the prevention and control of zoonoses since 2010, facilitating advocacy and operationalization of One Health at regional and country levels. The tripartite group and international partners have developed several One Health tools, which are useful for operationalization of One Health at the country level. Member States are encouraged to develop a One Health strategic framework taking into account the country’s context and priorities.
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Strengthening emergency preparedness and response systems: experience from Indonesia p. 26
Nyoman Kumara Rai, Kwang Il Rim, Endang Widuri Wulandari, Frieda Subrata, Anung Sugihantono, Vensya Sitohang
DOI:10.4103/2224-3151.282992  PMID:32341218
Indonesia has made excellent progress on emergency preparedness in compliance with the International Health Regulations, 2005, including a joint external evaluation (JEE) of IHR core capacities in 2017. Development of the National action plan for health security (NAPHS) began soon after the JEE, through multisectoral coordination and collaboration and with the support of a presidential instruction. The logic model approach was used to develop the NAPHS, and provided a robust framework to ensure that activities were linked to indicators at the various capacity levels delineated in the JEE. The NAPHS includes a comprehensive tool within which monitoring and evaluation are completely separated and different indicators applied. Furthermore, development of the NAPHS was done in parallel and in line with that of the National medium-term development plan 2020–2024, which included a focus on health system strengthening based on the primary health-care approach. An innovative approach taken in 2018 was the inclusion of emergency preparedness in the mandatory minimum service standards for provincial and district governments. These standards clearly articulate the importance of local emergency preparedness in Indonesia’s decentralized governance through the development of contingency plans and simulation exercises for natural disasters and potential disease outbreaks. Development of the NAPHS has benefited from Indonesia’s extensive experience in pandemic influenza preparedness planning and exercises, integrated with a national disaster management system. By signing the Delhi Declaration on Emergency Preparedness in the South-East Asia Region, Indonesia has signalled its commitment to implementing the NAPHS in full, focusing on enhanced emergency preparedness at all administrative levels.
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Strengthening emergency preparedness through the WHO emergency medical team mentorship and verification process: experience from Thailand p. 32
Kai von Harbou, Narumol Sawanpanyalert, Abigail Trewin, Richard Brown, John Prawira, Anil K Bhola, Arturo Pesigan, Roderico H Ofrin
DOI:10.4103/2224-3151.282993  PMID:32341219
The World Health Organization (WHO) emergency medical team (EMT) mentorship and verification process is an important mechanism for providing quality assurance for EMTs that are deployed internationally during medical emergencies. To be recommended for classification, an organization must demonstrate compliance with guiding principles and core standards for international EMTs and all technical standards for their declared type, in accordance with a set of globally agreed minimum standards. A rigorous peer review of a comprehensive documentary evidence package, combined with a 2-day verification site visit by WHO and independent experts, is conducted to assess an EMT’s capacity. Key requirements include having sufficient systems, equipment and procedures in place to ensure an EMT can deploy rapidly, providing clinical care according to internationally accepted standards, being able to be fully self-sufficient for a period of 14 days and being able to fully integrate into the emergency response coordination structure and the health system of the country affected during deployment. Through the WHO mentorship programme, each EMT is provided with a mentor team, which guides and supports it during the preparatory process. The process typically takes around 1 to 2 years to complete. The Thailand EMT is the first team from the WHO South-East Asia Region to successfully complete the WHO mentorship and verification process. The experience of this process in Thailand can serve as an example for other countries in the South-East Asia Region and encourage them to strengthen their emergency preparedness and operational readiness by getting their national EMTs verified.
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Building operational readiness for responding to emergencies in the WHO South-East Asia Region p. 37
Arturo Pesigan, Anil K Bhola, Hyon C Pak, Sugandhika Perera, John Prawira, Kai von Harbou, Sourabh K Sinha, Nilesh Buddha, Tamara Curtin Niemi, Egmond Evers, Roderico H Ofrin
DOI:10.4103/2224-3151.282994  PMID:32341220
The World Health Organization (WHO) has an essential role to play in supporting Member States to prepare for, respond to and recover from emergencies with public health consequences. Operational readiness for known and unknown hazards and emergencies requires a risk-informed and structured approach to building capacities within organizations such as WHO offices and national ministries of health. Under the flagship priority programme on emergency risk management of the WHO Regional Office for South-East Asia, a readiness training programme consisting of four modules was implemented during 2017–2018, involving staff from WHO country offices as well as from the regional office. The experience of and lessons learnt from designing, developing and delivering this phased training programme have fed into improvements in the curriculum and training methodology. The training programme has also facilitated the development of business continuity plans and contingency plans in some of the 11 Member States of the region and has increased the readiness of WHO staff for swift deployment in recent emergencies. It is recommended that the strengthening of operational readiness for responding to emergencies in the region be sustained and accelerated through the development of a regional training consortium that can scale the training programme up at national level, taking into account country contexts, national health systems and the needs of populations. The resilience of the populations and health systems in the region will be increased if disaster risk reduction and emergency preparedness and response activities are supported by operational readiness.
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Pandemic influenza preparedness in the WHO South-East Asia Region: a model for planning regional preparedness for other priority high-threat pathogens p. 43
Pushpa R Wijesinghe, Roderico H Ofrin, Anil K Bhola, Francis Y Inbanathan, Supriya Bezbaruah
DOI:10.4103/2224-3151.282995  PMID:32341221
Pandemic influenza preparedness has contributed significantly to building, strengthening and maintaining countries’ core capacities to prepare for health emergencies. The Pandemic influenza preparedness framework for the sharing of influenza viruses and access to vaccines and other benefits (the PIP framework) was adopted by the World Health Assembly in 2011. The experiences and lessons learnt from the implementation of the PIP framework have provided insights that can be used to strengthen preparedness for epidemics of other priority high-threat pathogens in the World Health Organization (WHO) South-East Asia Region in line with obligations under the International Health Regulations, 2005 (IHR). Implementation has established policies, strategies, action plans, strengthened systems and operational readiness to promptly diagnose influenza virus strains with pandemic potential and ensure timely event notifications and management in compliance with the IHR. WHO collaborating centres and the annual bi-regional meeting of national influenza centres and influenza surveillance have strengthened the influenza laboratory diagnostic knowledge network in the region. After action reviews following influenza outbreaks have documented best practices, strengths, constraints and areas for improvement in pandemic preparedness. The pandemic in 2009 and recent seasonal influenza outbreaks have offered real-life scenarios for testing national pandemic influenza preparedness plans and deploying vaccines. The successful implementation of the PIP framework, along with strengthening of health systems and operational procedures and continued technical collaboration with global centres of excellence, should be tapped into to strengthen preparedness to respond to epidemics of other high-threat pathogens based on the influenza model. The political commitment reflected in the Delhi Declaration on Emergency Preparedness, signed by all ministers of health in September 2019 and supported by the Five-year regional strategic plan to strengthen public health preparedness and response – 2019-2023, should be a catalyst for guidance and support in developing a broad, long-term strategic plan for preparedness and response to high-threat pathogens in the region.
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Animal welfare, One Health and emergency preparedness and response in the Asia-Pacific region p. 50
Gyanendra Gongal, Roderico H Ofrin
DOI:10.4103/2224-3151.282996  PMID:32341222
The Asia-Pacific region is vulnerable to a wide range of emergencies and natural disasters that are becoming more frequent because of seismic activity, climate change and changes in human development. For the rural poor in low-income settings, animals are valued beyond their financial worth as a fundamental part of human existence and livelihoods. Despite this recognition, animals are rarely included in national disaster plans and investments, and their needs are rarely factored into relief operations. Any natural disaster has short-term and long-term consequences that affect animals along with humans. For example, post-disaster community rehabilitation programmes may be strengthened by factors such as compensation for livestock losses. Emergency and disaster preparedness, response and recovery planning should follow the One Health approach by considering animal welfare, including rehabilitation and economic recovery.
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Why do many basic packages of health services stay on the shelf? A look at potential reasons in the WHO South-East Asia Region p. 52
Lluís Vinyals Torres, Valeria de Oliveira Cruz, Xavier Modol, Phyllida Travis
DOI:10.4103/2224-3151.282997  PMID:32341223
Basic packages of health services (BPHSs) are often envisaged primarily as political statements of intent to provide access to care, in an era of commitment to universal health coverage. They are often produced with little attention paid to health systems’ capacity to deliver these benefit packages or other implementation challenges. Many countries of the World Health Organization (WHO) South-East Asia Region have invested in developing BPHSs. This perspective paper reflects on the issues that do not receive enough attention when packages are developed, which can often jeopardize their implementation. Countries of the region refer to burden-of-disease assessments and consider the cost-effectiveness of the listed interventions during their BPHS design processes. Some also conduct a costing study to generate “price tags” that are used for resource mobilization. However, important implementation challenges such as weak supply-side readiness, limited scope for reallocation of existing resources and management not geared for accountability are too often ignored. Implementation and its monitoring is further hampered by the limitations of existing health information systems, which are often not ready to collect and analyse data on emerging interventions such as noncommunicable disease management. Among the countries of the WHO South-East Asia Region, those with better chances of executing their BPHSs have adapted their packages to their implementation, financing and monitoring capacities, and have considered the need for a modified service delivery model able to provide the agreed services.
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ORIGINAL RESEARCH Top

Seasonal influenza surveillance (2009–2017) for pandemic preparedness in the WHO South-East Asia Region p. 55
Members of the WHO South-East Asia Region Global Influenza Surveillance and Response System
DOI:10.4103/2224-3151.282999  PMID:32341224
Background Influenza causes seasonal outbreaks each year and periodically causes a pandemic. The World Health Organization (WHO) Global Influenza Surveillance and Response System (GISRS) has contributed to global understanding of influenza patterns, but limited regional analysis has occurred. This study describes the virological patterns and influenza surveillance systems in the 11 countries of the WHO South-East Asia Region. Methods Virological data were extracted in January 2018 from FluNet, GISRS’s web-based reporting tool, for 10 of the 11 countries that had data available for the years 2009 to 2017. Descriptive data for 2017 on influenza surveillance systems, including the number of sentinel sites, case definitions and reporting frequency, were collected through an annual questionnaire. Results Data on surveillance systems were available for all 11 Member States, and 10 countries reported virological data to FluNet between 2009 and 2017. Influenza surveillance in the region and national participation increased over the 8 years. Seasons varied between countries, with some experiencing two peak seasons and others having one main predominant season. Bangladesh, Indonesia and Myanmar have only one season: Bangladesh and Myanmar have a mid-year pattern and Indonesia an end-year pattern. Influenza A was the predominant circulating type for all years except 2012 and 2016, when A and B co-circulated. Influenza A(H1N1)pdm09 was dominant in 2009 and 2010 (77% and 76%, respectively), 2015 (72%) and 2017 (54%); influenza A(H3) accounted for approximately half of the positive specimens in 2011 (46%), 2013 (51%) and 2014 (47%); and influenza B (lineage not determined) made up over 49% of positive specimens in 2012. Conclusion Although the timings of peaks varied from country to country, the viruses circulating within the region were similar. Influenza surveillance remains a challenge in the region. However, timely reporting and regional sharing of information about influenza may help countries that have later peaks to allow them to prepare for the potential severity and burden associated with prevailing strains.
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Assessment of drought resilience of hospitals in Sri Lanka: a cross-sectional survey p. 66
Novil W A N Y Wijesekara, Asanka Wedamulla, Sugandhika Perera, Arturo Pesigan, Roderico H Ofrin
DOI:10.4103/2224-3151.283000  PMID:32341225
Background Drought is an extreme weather event. Drought-related health effects can increase demands on hospitals while restricting their functional capacity. In July 2017, Sri Lanka had been experiencing prolonged drought for around a year and data on the resilience of hospitals were required. Methods A cross-sectional survey was done in five of the most drought-affected and vulnerable districts using two specially developed questionnaires. Ninety hospitals were assessed using the Baseline Hospital Drought Resilience Assessment (BHDRA) tool, of which 24 purposefully selected hospitals were also assessed using the more detailed Comprehensive Hospital Drought Resilience Assessment (CHDRA) tool and observation visits. Results Of the hospitals assessed, 73 and 77 reported having adequate supplies of drinking and non-drinking water, respectively. Of the 24 hospitals studied using the CHDRA tool, bacteriological water quality testing was done in 8, with samples from only 4 hospitals being satisfactory. Adequate electricity supply was reported by 77 hospitals, of which 72 had at least one generator. None of the hospitals used rainwater or storm water harvesting, water recycling, or solar or wind power. Of the 24 hospitals selected for detailed analysis, awareness materials on safeguarding water or electricity and avoiding wasting water or electricity were displayed in only 6 hospitals; disaster preparedness plans were available in 9; and drought was considered as a hazard only in 6. Conclusion The findings indicate that drought needs to be considered as an important hazard in hospital risk assessments. Drought preparedness, response and recovery should be embedded in hospital disaster preparedness plans to ensure the continuity of essential health services during emergencies.
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Changes in the affordability of tobacco products in India during 2007/2008 to 2017/2018: a price-relative-to-income analysis p. 73
Mark Goodchild, Praveen Sinha, Vineet Gill Munish, Fikru Tesfaye Tullu
DOI:10.4103/2224-3151.283001  PMID:32341226
Background Increasing the price of tobacco through taxation is a very effective means of reducing tobacco use. However, the impact of price increases can be diluted if consumer incomes are growing strongly. The affordability of tobacco products has, therefore, become an important indicator for tobacco control. This study asks whether tobacco products in India became more or less affordable during 2007/2008 to 2017/2018. Methods Survey data on the retail price of chewing tobacco, bidis and cigarettes were used to measure affordability at state and national levels. We adapted the price relative to income measure by calculating the percentage of net state domestic product (NSDP) per capita needed to purchase 1000 g of tobacco in each form and then calculating the average annual percentage change (AAPC) in affordability. We used ordinary least squares regression analysis to test for any changes. Results In 2017/2018, it took 1.72% and 1.18% of NSDP/capita to purchase 1000 g of tobacco in the form of bidis and chewing tobacco respectively. The affordability of bidis remained unchanged, while chewing tobacco became more affordable (AAPC = −1.83%, 95% confidence interval −2.87 to −0.80, P = 0.003). For cigarettes, it took 7.56% of NSDP/capita to purchase 1000 g of tobacco in 2017/2018; although affordability decreased in many states, national average affordability was unchanged. Conclusion Tobacco products, especially indigenous forms such as bidis and chewing tobacco, have not become measurably less affordable over the past decade. India should raise taxes on all tobacco products to significantly reduce the affordability of these products and to promote public health.
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POLICY AND PRACTICE Top

Community action for health in India: evolution, lessons learnt and ways forward to achieve universal health coverage p. 82
Chandrakant Lahariya, Bijit Roy, Abhay Shukla, Mirai Chatterjee, Hilde De Graeve, Manoj Jhalani, Henk Bekedam
DOI:10.4103/2224-3151.283002  PMID:32341227
The role of civil society and community-based organizations in advancing universal health coverage and meeting the targets of the 2030 Agenda for Sustainable Development has received renewed recognition from major global initiatives. This article documents the evolution and lessons learnt through two decades of experience in India at national, state and district levels. Community and civil society engagement in health services in India began with semi-institutional mechanisms under programmes focused on, for example, HIV/AIDS, tuberculosis, polio and immunization. A formal system of community action for health (CAH) started with the launch of the National Rural Health Mission in 2005. By December 2018, CAH processes were being implemented in 22 states, 353 districts and more than 200 000 villages in India. Successive evaluations have indicated improved performance on various service delivery parameters. One example of CAH is community-based monitoring and planning, which has been continuously expanded and strengthened in Maharashtra since 2007. This involves regular, participatory auditing of public health services, which facilitates the involvement of people in assessing the public health system and demanding improvements. At district level, CAH initiatives are successfully reaching “last-mile” communities. The Self-Employed Women’s Association, a cooperative-based organization of women working in the informal sector in Gujarat, has developed community information hubs that empower clients to access government social and health sector services. CAH initiatives in India are now being augmented by regular activities led and/or participated in by civil society organizations. This is contributing to the democratization of community and civil society engagement in health. Additional documentation on CAH and the further formalization of civil society engagement are needed. These developments provide a valuable opportunity both to improve governance and accountability in the health sector and to accelerate progress towards universal health coverage. Lessons learnt may be applicable to other countries in South-East Asia, as well as to most low- and middle-income countries.
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