Analysis of sectoral participation in the development of Joint External Evaluations

Of the 193 member states of the WHO, 47 had published English-language JEE reports by March 31, 2018. Regional breakdowns of JEE participants delineate involvement in this process, with the Eastern Mediterranean and African regions providing the most representation in terms of percentage of countries who have gone through the JEE process and the region of the Americas and European region providing the least representation (Fig. 1).

Most countries were well represented in their JEEs by public entities in health (100% of countries), agriculture (95%), domestic security (91%), and environment (86%). Additionally, 72% of countries had representation by the transportation sector, with representation provided by ports rather than governmental departments in 21% of countries. The energy/nuclear (58%), defense (56%), and international cooperation (40%) sectors were less frequently represented in JEEs. Furthermore, within the health sector, the subcategories of patient care/hospitals (65% of countries), epidemiology/surveillance (58%), emergency/ambulatory services (49%), and food safety (49%) were the most well represented, with nutrition/food safety (12%) and zoonotic disease (9%) less frequently represented.

With the exception of privately-owned ports, the addition of involvement by private entities to sector representation in the JEEs did not greatly increase the diversity of representation. Instead, these entities generally bolstered the health and agriculture sectors that were already represented by public entities. (Figure 2) Of the private entities that helped bolster involvement within the health sector, most served to strengthen the epidemiology/surveillance sub-category, with 74% of countries represented overall as compared to 58% with public entities alone. Most involvement from private entities is provided by NGOs, with 58% of countries including an NGO in their JEE, followed by state-sanctioned aid (i.e. aid groups sponsored by a foreign government) (40%), universities (30%), and businesses (16%).

Regional differences were seen in the key host country participants and institutions involved in the JEEs. All countries evaluated in the South-East Asia and Western Pacific regions had representation by entities with a national defense mission. In comparison, the defense sector was less often represented in JEEs for countries in the African (50% of countries), Eastern Mediterranean (40%), and European (38%) regions. JEEs in the South-East Asia and Western Pacific regions also showed frequent representation in the international cooperation sector at 75 and 80% respectively. In contrast, organizations involved in international cooperation were less frequently involved in JEEs performed in the African (29% of countries), Eastern Mediterranean (30%), and European regions (25%). One-hundred percent of countries in all regions had representation by the environment sector with the exception of the African and European regions, which had 86 and 50% representation respectively. Additionally, ports contributed significantly to transportation representation in all regions except for the African region.

The Eastern Mediterranean region had the highest representation of business involvement with 60% of countries including a business in their JEE, with the next closest region being African at 36%. Assistance from NGOs was high in the African (86%), South-East Asia (75%), and Eastern Mediterranean (70%) regions. Additionally, the African region had the highest involvement from state-sanctioned aid organizations compared to other regions and over half of all countries in the African, South-East Asia, and European regions had assistance from universities in the JEE process. Regional data from the Region of the Americas is not included as it is only represented by the United States of America.

Mission team members primarily represented the health and agriculture sectors, with 100% of JEEs including one or more mission team members with a background in health and 85% with one or more mission team members with a background in agriculture. International cooperation, as represented by mission team members in 23% of JEEs, was the next most represented sector.

All JEEs included one or more mission team member(s) from both an international organization and a domestic organization. Independent consultants were also frequently used as mission team members, serving on the mission team for 43% of all JEEs. Notable consultant backgrounds include communication and advocacy specialists, public health legal advisors, an emergency response operations consultant, risk communication consultants, and a laboratory biosafety and biosecurity and quality management system specialist. Mission team members from businesses and universities were present in 11% of JEEs.

Strong representation in the JEE process by the health (100% of countries), agriculture (95%), and environment (86%) sectors is to be expected, as these sectors are traditionally considered essential to public health preparedness. Health in particular relates to every JEE criterion used to assess a country’s capacity for preparedness from prevention efforts including immunization and antimicrobial resistance, detection efforts including epidemiological surveillance and diagnostic testing, and response efforts including medical countermeasures and the deployment of health personnel. Additionally, the link between health and the agriculture and environment sectors, particularly in the case of pandemic preparedness, is readily apparent, as serious issues related to human health such as zoonotic disease and food safety and security encompass agricultural and environmental health as well. Relatively high involvement of the transportation sector (72%) in JEE participants also is not surprising, as the JEE criterion focused on including points of entry in preparedness measures aims to minimize the risk of disease from crossing borders through bolstering quarantine procedures at national entry points. Gupta and colleauges evaluated JEE scores as a quantitative metric of public health preparedness and response capabilities, illustrating a strong correlation between JEE performance and health outcomes and validating the JEE process as a viable tool in global emergency preparedness-building. [13]

Involvement of security agencies has been recognized as essential in developing effective preparedness plans, particularly in surveillance and response operations [14]. The strong representation of security with 91% of countries including a public agency representing the domestic security sector in their JEE is therefore promising, as the institutions within this sector have the capacity to provide the essential functions of maintaining public safety and order through law enforcement branches and contributing to emergency response through disaster management organizations. Despite this, there are many functions that the military has the capacity to provide that institutions in the domestic security sector do not, including providing logistics support on a mass scale, response to large-scale disasters, and peace-keeping operations [9]. Additionally, emergency situations including pandemics may result in situations with military involvement, particularly if there is civil unrest, large-scale refugee situations, border incursions, and the escalation of conflict [9]. Lower involvement by defense (56% of JEE participants) may reflect a need for increased attention to the public health preparedness contributions of this sector.

The energy/nuclear sector (58% of countries) would have a key role in response to a radiological or nuclear event. Ensuring that preparedness measures for these events are in place is part of the IHR 2005 revision, with a JEE criterion specifically devoted to preparedness in radiological emergencies. Other JEE criteria, such as detection operations, personnel deployment, and risk communication depend on a country’s capacity to have a specific plan in place for these types of events, which likely would involve organizations from the energy/nuclear sector.

Strong participation in the health subcategories of patient care/hospitals (65% of countries), epidemiology/surveillance (58%), and emergency/ambulatory services (49%) is promising, as it indicates the inclusion of these key health areas in public health preparedness activities. Low representation by the nutrition/food security (12%) and zoonotic disease (9%) subcategories may be the result of topic areas being represented by entities in other sectors, including agriculture and environment.

The inclusion of private entities in JEEs around the world, primarily NGOs (58% of JEE participant countries) and state-sanctioned aid organizations (40%), followed by universities (30%) and businesses (16%) is promising. Institutions in the private sector are essential to developing business continuity plans in the event of an emergency to ensure that essential services such as medication distribution and basic utilities continue in civil society. They also are instrumental in helping the government with supply chain vulnerabilities and communication technology system failures such as the internet [9]. Though private entities were involved in the JEE process for many countries, they did not serve to increase the diversity of sector representation, merely bolstering the health and agriculture sectors that already had strong representation by public entities. Because private entities play a multitude of roles contributing to the functioning of civil society, they should be more diversely represented in preparedness efforts.

Countries in the South-East Asia and Western Pacific regions had overall strong multisectoral representation, with 100% of countries in these regions including an organization representing the defense and environment sectors and 75 and 80% including an organization representing international cooperation respectively. These findings align with recent efforts by the Association of Southeast Asian Nations (ASEAN), which includes countries from both the WHO South-East Asia and Western Pacific regions, to bolster multisectoral public health preparedness in the region. This commitment to broadening the scope of sectoral involvement in preparing for public health emergencies has been ongoing since the establishment of the ASEAN Multi-Sector Pandemic Preparedness and Response Work Plan in 2008, which assigned identified key sectors in response efforts, created business continuity plans for times of crisis, and linked pandemic preparedness to the disaster response system [9].

In key sectors where representation was high in the South-East Asia and Western Pacific regions, it was markedly low in the Eastern Mediterranean and African regions (defense, 40 and 50% respectively; international cooperation, 30 and 29% respectively). Additionally, countries in the Eastern Mediterranean and African regions had the most representation by private entities, with 86% of countries in the African region and 70% of countries in the Eastern Mediterranean region including an NGO in their JEE and a relatively high proportion of Eastern Mediterranean countries including a business (60%). Furthermore, the majority of countries in the African region included state-sanctioned aid organizations and universities in their JEE. This trend of comparatively lower involvement by public entities in key sectors and the increased enlistment of assistance by private entities may be due in part to political instability and ongoing crises in these regions. Of the countries listed by the WHO as experiencing Grade 2 and Grade 3 public health emergencies, defined as current situations requiring moderate to substantial emergency support by outside groups, 80% of these are from the Eastern Mediterranean and African Regions [15]. Countries with significant public health and political turmoil in the Eastern Mediterranean region in particular have been cited as having technical and political difficulties in the JEE process [15]. Due to the increased enlistment of aid organizations in emergency response situations in these regions, it is not surprising that a higher level of private entities are included as key partners in the JEE process as they may already play a key role in developing the health capacity and infrastructure for these countries.

Compared to its counterparts, the European region had relatively low representation in key sectors including environment (50% of countries), defense (38%), and international cooperation (25%). This is surprising, given the region’s commitment to the European Action Plan to Improve Public Health Preparedness and Response, which emphasizes linking emergency preparedness networks with health systems and improving collaboration between sectors [16]. Our results indicate that the European region may have a different approach to public health preparedness, prioritizing different sectors to include in emergency response plans. Additionally, the lack of representation across sectors may be influenced by the fact that only 15% of WHO European region member states have participated in the JEE process to date, with the majority of these countries concentrated in the eastern region of Europe.

While host countries overall have good multisectoral representation in their JEEs, members of the mission teams are overwhelmingly from the health and agriculture sectors. In contrast, the standardized process of mission team staffing emphasizes organizational and background diversity [5]. Though a need for strong multisectoral representation in developing preparedness action plans has been demonstrated to be beneficial, the importance of mission team members from diverse backgrounds is not clear. The ability to evaluate a country’s capacity to respond to the predetermined evaluation criteria in the JEE process may not be dependent on multisectoral representation by peer evaluators.

A total of 6 JEE reports, not published in English, were excluded from the analysis to avoid misclassification of key participants into relevant sectoral categories due to translation errors, limiting the representativeness of this study. This analysis relied on host country lists of key participants in JEE development. The extent to which key participants are engaged in the JEE process was not delineated by Member States and therefore could not be addressed in this analysis. Additionally, because sector involvement was defined as a country having one or more organizations representing a particular sector, our results do not distinguish between countries with more or fewer participating organizations. Our analysis does not intend to convey a country or region’s level of preparedness within any particular sector, but rather to determine engagement across multiple sectors and identify overall gaps in the hopes of informing which sectors need to be bolstered to facilitate a more integrated approach to preparedness.