ArticlePDF Available

Reviewing Health Security Capacities in Nigeria Using the Updated WHO Joint External Evaluation and WHO Benchmarks Tool: Experience from a Country-Led Self-Assessment Exercise

Authors:
  • Nigeria Centre for Disease Control

Abstract and Figures

Across the world, the level of pandemic preparedness varies and no country is fully prepared to respond to all public health events. The International Health Regulations 2005 require state parties to develop core capacities to prevent, detect, and respond to public health events of international concern. In addition to annual self-assessment, these capacities are peer reviewed once every 5 years through the voluntary Joint External Evaluation (JEE). In this article, we share Nigeria's experience of conducting a country-led midterm self-assessment using a slightly modified application of the second edition of the World Health Organization (WHO) JEE and the new WHO benchmarks tool. Despite more stringent scoring criteria in the revised JEE tool, average scoring showed modest capacity improvements in 2019 compared with 2017. Of the 19 technical areas assessed, 11 improved, 5 did not change, and 3 had lower scores. No technical area attained the highest-level scoring of 5. Understanding the level of, and gaps in, pandemic preparedness enables state parties to develop plans to improve health security; the outcome of the assessment included the development of a 12-month operational plan. Countries need to intentionally invest in preparedness by using existing frameworks (eg, JEE) to better understand the status of their preparedness. This will ensure ownership of developed plans with shared responsibilities by all key stakeholders across all levels of government.
Content may be subject to copyright.
Reviewing Health Security Capacities in Nigeria
Using the Updated WHO Joint External Evaluation
and WHO Benchmarks Tool: Experience from a
Country-Led Self-Assessment Exercise
Olukayode Fasominu, Oyeladun Okunromade, Oyeronke Oyebanji, Christopher T. Lee, Adejare Atanda,
Ibrahim Mamadu, Ifeanyi Okudo, Ebere Okereke, Elsie Ilori, and Chikwe Ihekweazu
Across the world, the level of pandemic preparedness varies and no country is fully prepared to respond to all public health events.
The International Health Regulations 2005 require state parties to develop core capacities to prevent, detect, and respond to
public health events of international concern. In addition to annual self-assessment, these capacities are peer reviewed once every
5 years through the voluntary Joint External Evaluation ( JEE). In this article, we share Nigeria’s experience of conducting a
country-led midterm self-assessment using a slightly modified application of the second edition of the World Health Orga-
nization (WHO) JEE and the new WHO benchmarks tool. Despite more stringent scoring criteria in the revised JEE tool,
average scoring showed modest capacity improvements in 2019 compared with 2017. Of the 19 technical areas assessed, 11
improved, 5 did not change, and 3 had lower scores. No technical area attained the highest-level scoring of 5. Understanding the
level of, and gaps in, pandemic preparedness enables state parties to develop plans to improve health security; the outcome of the
assessment included the development of a 12-month operational plan. Countries need to intentionally invest in preparedness by
using existing frameworks (eg, JEE) to better understand the status of their preparedness. This will ensure ownership of
developed plans with shared responsibilities by all key stakeholders across all levels of government.
Keywords: Joint External Evaluation, Preparedness, International Health Regulations, Public health preparedness/
response
Olukayode Fasominu, MD, MPH, is a National Consultant, Surveillance; Oyeladun Okunromade, MBBS, MPH, is Deputy Director,
Surveillance; Oyeronke Oyebanji, MSc, is a Technical Assistant, Office of the Director General; Elsie Ilori is Director, Surveillance;
and Chikwe Ihekweazu, MBBS, FFPH, is Director General; all at the Nigeria Centre for Disease Control, Abuja, Nigeria. Olukayode
Fasominu is also Principal, Volte Health Systems Limited, Abuja, Nigeria. Christopher T. Lee, MD, MSc, MPH, is Director, Global
Epidemic Preparedness and Response, Resolve to Save Lives, New York, NY. Adejare ( Jay) Atanda, DDS, MPH, is a Postdoctoral
Fellow, School of Community Health and Policy, Morgan State University, Baltimore, MD. Ibrahim Mamadu, MD, MPH, is a
National Programme Officer and Ifeanyi Okudo, MBBS, MPH, is Emergencies Cluster Lead; both in Health Emergency Preparedness
and International Health Regulations, World Health Organization Nigeria Country Office, Abuja, Nigeria. Ebere Okereke, MBBS,
MSc(PH), FFPHM, is Lead, Public Health England International Health Regulation (IHR) Strengthening Programme, International
Health Regulations Strengthening Project, Public Health England, London, UK.
ªOlukayode Fasominu, et al., 2021; Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of
the Creative Commons Attribution Noncommercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits any
noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.
Health Security
Volume 20, Number 1, 2022 Mary Ann Liebert, Inc.
DOI: 10.1089/hs.2021.0095
74
Open camera or QR reader and
scan code to access this article
and other resources online.
Introduction
Infectious disease outbreaks do not respect borders.
1
The speed at which disease outbreaks spread has drasti-
cally increased with globalization and ease of travel, as
demonstrated by the international spread of diseases in-
cluding Ebola,
1-3
Middle East respiratory syndrome,
4
se-
vere acute respiratory syndrome,
5
and COVID-19.
6-9
The
impact of these outbreaks and epidemics on health sys-
tems and populations is substantial, slowing and some-
times reversing socioeconomic gains.
10,11
Several disease
outbreaks have been recorded in Nigeria in the last 10 years
with imported cases of Ebola in 2014,
12
annual outbreaks
of yellow fever,
13,14
Lassa fever,
15-17
cerebrospinal meningi-
tis,
18
cholera,
19,20
measles,
21
and most recently, COVID-19.
22
Infectious disease outbreaks have exacerbated the humani-
tarian crises continuing in northeast Nigeria, reflecting the
interaction between humans, animals, and the environ-
ment.
23-25
Consequently, there is a continuous emphasis
on strengthening pandemic preparedness while prioritizing
response efforts to protect the population from disease
threats and ultimately improve health security.
25-27
In response to lessons learned from the severe acute
respiratory syndrome outbreak in 2003, the World Health
Organization (WHO) accelerated the revision of the Inter-
national Health Regulations (IHR), which were adopted
in 2005
28
and came into force in 2007. The IHR are
essential for addressing global health security
29
and its
implementation is underpinned by a comprehensive IHR
monitoring and evaluation framework.
30-32
The frame-
work, with its 4 components—State Party Self-Assessment
Annual Reporting tool, voluntary Joint External Evaluation
( JEE), after-action reviews, and simulation exercises—aims
to provide a comprehensive, accurate, country-level over-
view of the implementation requirements under the IHR.
The need for a monitoring and evaluation framework for
IHR compliance was highlighted by the inadequacies of
the annual self-reporting previously used as the sole indi-
cator of emergency preparedness and IHR compliance.
33
The JEE is an important structure on which to base health
security strengthening efforts, even if it does not predict
country performance during a pandemic. The most criti-
cal aspect to countries, more than the JEE scores, is how
countries respond.
34
Using the JEE to Strengthen Health
Security in Nigeria
Nigeria is a state party to the IHR and mandated to report
annually on its compliance status at the World Health
Assembly. In June 2017, Nigeria conducted a JEE,
35,36
which provided an opportunity for IHR stakeholders across
government ministries, departments, and agencies ( MDAs)
to jointly identify gaps in the country’s health security
capacity.
Following the JEE,
31
countries
37
use the findings to de-
velop a costed, multiyear National Action Plan for Health
Security (NAPHS)
38
aimed at addressing identified health
security gaps. In Nigeria, the NAPHS was developed with a
5-year timeline, costed, and launched,
36,39,40
which enabled
country stakeholders to implement a plan to strengthen
health security capacities using a One Health approach. In
Nigeria, developing the NAPHS facilitated access to a
credit facility from the World Bank Regional Disease
Surveillance Systems Enhancement project.
41
As the na-
tional IHR Focal Point, the Nigeria Centre for Disease
Control worked with other MDAs to begin the implemen-
tation of activities within the NAPHS,
36
with support from
the Regional Disease Surveillance Systems Enhancement
project
41
and other partners.
Given the long interval of 4 to 5 years before repeating
the JEE,
30
Nigeria developed a framework for a midterm
JEE to review its IHR core capacities in health security.
Many systems improvements had been made since the
initial JEE was conducted in 2017 and stakeholders needed
to align with a multisectoral plan to address key priorities.
The Nigeria Centre for Disease Control sought guidance
from WHO and from partner organizations working on
IHR implementation that served as national external ex-
perts, including US Centers for Disease Control and Pre-
vention, Public Health England, and Resolve to Save Lives.
The country-led, midterm JEE was conducted from
November 18 to 22, 2019.
42
The objectives were to: (1)
conduct a self-assessment of IHR implementation using the
updated second edition JEE tool, (2) review progress and
identify challenges in the implementation of the NAPHS,
(3) compare scores from the self-assessment with the WHO
benchmarks tool to identify core activities for health secu-
rity implementation and develop annual operational plans
specific to the JEE technical areas, and (4) map prioritized
health security activities to government and partner resources.
The JEE tool used in 2017 was updated by WHO in
2018.
43
The revised JEE tool and the WHO benchmarks
tool
44
now include a minimum set of prescriptions that
state parties should aspire to for each technical area to dem-
onstrate sufficient core capacity. Scoring in this updated
tool is dependent on multisectoral coordination and ac-
complished through a One Health approach.
29,43
By sharing Nigeria’s experience, we intend to re-
emphasize the need for countries to invest in similar efforts
that ensure collective contribution to strengthening health
security capacities. We envisage that implementing the
lessons from this process will stimulate a renewed drive
among countries for a self-sustaining model that embodies
the tenets of the IHR monitoring and evaluation frame-
work, through self-appraisal. These self-appraisals will po-
tentially lead to the development and execution of feasible
national and subnational action plans that support IHR
compliance and efforts to strengthen health security and
health systems using a multisectoral approach, with all
relevant stakeholders.
FASOMINU ET AL
Volume 20, Number 1, 2022 75
Country-Led Process for the
Midterm JEE
The midterm JEE in Nigeria was a hybrid process that
incorporated an internal assessment and review by a team
of evaluators from development partners and public health
institutions working in health security implementation.
The internal assessment commenced with a preworkshop
where technical leads: (1) were updated on the revised
second edition JEE and the WHO benchmarks tool, (2)
conducted a review of self-assessed JEE scores with feedback
provided by a team of subject matter experts on the draft
report documenting progress made since the 2017 JEE
including the rationale for scores, and (3) prioritized 2 to 3
benchmark actions for implementation in 2020 using the
WHO benchmarks tool, based on the implementation
challenges observed since the NAPHS was launched in
2018 and on systems performance as measured by real-
world events, including after-action reviews of MDAs.
44
Before the midterm assessment, technical area leads re-
viewed results of previously conducted after-action reviews
and simulation exercises to prioritize selected benchmarks,
demonstrate progress, and spotlight challenges with im-
plementing recommendations from the first JEE. The
benchmark tool, which was used as a planning rather than
an assessment tool, helped identify actions to move to the
next level. Participation during the midterm JEE included
state epidemiologists, given their critical roles in coordi-
nating response to public health events at the subnational
level.
45
The evaluation included discussions (at plenary)
around the progress and challenges since the development
of the NAPHS, and reaching consensus on capacity scores
and priority actions for implementation. We used mean
scores to determine changes in Nigeria’s JEE scores by
technical area and indicator between 2017 and 2019
(Table 1).
Subsequently, a 1-year operational plan for 2020 was
developed, and responsibilities were assigned to respective
MDAs with a proposed implementation timeline and
tracker. Feedback was provided to the country team at a
high-level stakeholders’ meeting after a team of external
evaluators from development partner agencies and host-
country experts had obtained full agreement on all aspects
of the report findings and recommendations. Core to this
process was the wide engagement of key stakeholders across
relevant MDAs with a role to play in IHR implementation.
Status of Health Security Capacity
Following the Midterm JEE
Of the 19 technical areas assessed, 11 recorded increases
in the mean score of their composite indicators compared
with the 2017 JEE (Table 1), 5 showed no change in
scoring, and 3 showed lower scores (Table 2). No indicator
attained the highest-level scoring of 5. Key national prior-
ities for action (Table 3) were identified following the
exercise. JEE scores indicate the level of health security
capacity on a scale from 1 to 5: 1 =no capacity, 2 =limited
capacity, 3, developed capacity, 4 =demonstrated capacity,
5=sustainable capacity.
43
Prevent
Scores for national legislation, policy, and financing;
zoonotic diseases; and biosafety and biosecurity increased
under the Prevent core area between 2017 and 2019. The
score for national legislation and policy increased from 1
to 2. Two new indicators were added to the financing
component of this technical area and served as new base-
line scoring. Challenges identified included an incomplete
review of the Public Health Act Bill (2013)
46
and the
National Health Act (2014)
47
by the legislative arm of
government. It was evident that there was an overwhelming
need for training of dedicated technical officers across IHR
implementing MDAs on the relevance of IHR and aware-
ness of existing guiding policies.
In the zoonotic diseases technical area, scores increased
for 2 indicators as follows: indicator P4.1 (coordinated
surveillance systems in place) increased from 2 to 3, and
indicator P4.2 (mechanisms for responding to diseases)
increased from 1 to 3. A key challenge was the discordance
between prioritized NAPHS activities and findings from
the 2017 JEE. Therefore, there was no mutual account-
ability for the implementation of these activities by the
responsible MDAs. The score for 1 indicator, P6.1 (whole-
of-government biosafety and biosecurity) under the bio-
safety and biosecurity technical area, increased from 1 to 2.
Institutionalizing training programs for biosafety labora-
tory staff was identified as key to addressing the limited
numbers of skilled personnel across the laboratories.
Scores for indicators in antimicrobial resistance, food
safety, and immunization decreased. A score of 4 was at-
tained for new indicator P3.1 (effective multisectoral co-
ordination on antimicrobial resistance). For indicators P3.3
(infection prevention and control) and P3.4 (optimize use
of antimicrobial medicines in human and animal health
and agriculture), scoring decreased compared with 2017,
from 2 to 1. A major gap was the need to explicitly capture
activities that focus on the environment within the One
Health operational plan, and publishing documents ad-
dressing appropriate use, availability, and quality of anti-
microbials to optimize the use of antimicrobial medicines
in human and animal health. Key challenges experienced in
this technical area included a delay in presidential assent to
an amended Animal Disease Control Act, and nonexistent
specific regulations for antimicrobial stewardship for both
human and animal health.
Scoring for food safety technical area decreased from 2
to 1 but reflected a more stringent and rigorous core ca-
pacity requirement. Despite the existence of a framework
to respond to and manage food safety emergencies, there
was no evidence of the functionality of such frameworks.
REVIEWING HEALTH SECURITY CAPACITIES IN NIGERIA
76 Health Security
Table 1. Changes in Nigeria’s JEE Scores by Technical Area and Indicator, 2017 to 2019
Technical Area Indicator
JEE Score
a
(2017)
Self-Assessed
Score (2019) Change
Average Change
per Technical
Area
Prevent
National legislation,
policy, and
financing
P1.1: The state has assessed, adjusted, and
aligned its domestic legislation, policies,
and administrative arrangements in all
relevant sectors, to enable compliance
with the IHR (combines P1.1 and P1.2
from JEE version 1)
12[1to2
([)
P1.2: Financing is available for the
implementation of IHR capacities
(new indicator in JEE version 2)
2 New
P1.3: A financing mechanism and funds are
available for timely response to public
health emergencies (new indicator in JEE
version 2)
2 New
IHR coordination,
communication,
and advocacy
P2.1: A functional mechanism established
for the coordination and integration of
relevant sectors in the implementation of
IHR
2242to2
(4)
Antimicrobial
resistance
P3.1: Effective multisectoral coordination on
AMR (new indicator in JEE version 2)
4 New 2 to 2
(4)
P3.2: Surveillance of AMR (combines
P3.1 and P3.2 from JEE version 2)
224
P3.3: Infection prevention and control 2 1 Y
P3.4: Optimize use of antimicrobial
medicines in human and animal health
and agriculture
21Y
Zoonotic disease P4.1: Coordinated surveillance systems in
place in the animal health and public
health sectors for zoonotic diseases/
pathogens identified as joint priorities
23[1.5 to 3
([)
P4.2: Mechanisms for responding to
infectious and potential zoonotic diseases
established and functional (previously
P4.3)
13[
Food safety P5.1: Surveillance systems in place for the
detection and monitoring of foodborne
diseases and food contamination
21Y2to1
(Y)
P5.2: Mechanisms are established and
functioning for the response and
management of food safety emergencies
1Y
Biosafety and
biosecurity
P6.1: Whole-of-government biosafety and
biosecurity system is in place for all sectors
(including human, animal, and agriculture
facilities)
12[1 to 1.5
([)
P6.2: Biosafety and biosecurity training and
practices in all relevant sectors (including
human, animal, and agriculture)
114
(continued)
Volume 20, Number 1, 2022 77
Table 1. (Continued)
Technical Area Indicator
JEE Score
a
(2017)
Self-Assessed
Score (2019) Change
Average Change
per Technical
Area
Immunization P7.1: Vaccine coverage (measles) as part of
national program
32Y3.5 to 3
(Y)
P7.2: National vaccine access and delivery 4 4 4
Detect
National laboratory
system
D1.1: Laboratory testing for detection of
priority diseases
34[2 to 2.8
([)
D1.2: Specimen referral and transport
system
12[
D1.3: Effective national diagnostic network 2 3 [
D1.4: Laboratory quality system 2 2 4
Surveillance D2.1: Surveillance systems (combines D2.1
and D2.4 of JEE version 1)
32Y2.7 to 2.7
(4)
D2.2: Use of electronic tools 2 3 [
D2.3: Analysis of surveillance data 3 3 4
Reporting D3.1: System for efficient reporting to FAO,
OIE, and WHO
34[2.5 to 3.5
([)
D3.2: Reporting network and protocols
in-country
23[
Human resources
(animal and
human health
sectors)
D4.1: An up-to-date multisectoral workforce
strategy in place (previously D4.3)
2243 to 2.8
(Y)
D4.2: Human resources are available to
effectively implement IHR (previously
D4.1)
334
D4.3: In-service trainings are available (new
indicator in JEE version 2)
3 New
D4.4: Field Epidemiology Training Program
or other applied epidemiology training
program is in place (previously D4.2)
43Y
Respond
Emergency
preparedness
R1.1: Strategy emergency risk assessments
conducted and emergency resources
identified and mapped
12[1 to 1.5
([)
R1.2: National multisectoral, multihazard
emergency preparedness measures,
including emergency response plans, are
developed, implemented, and tested
114
Emergency response
operations
R2.1: Emergency response coordination
(new indicator in JEE version 2)
23[2.3 to 3.3
([)
R2.2: Emergency operation centers’
capacities, procedures, and plans (combines
R2.1 and R2.2 from JEE version 1)
23[
R2.3: Emergency exercise management
program
34[
(continued)
78 Health Security
Table 1. (Continued)
Technical Area Indicator
JEE Score
a
(2017)
Self-Assessed
Score (2019) Change
Average Change
per Technical
Area
Linking public
health and
security
authorities
R3.1: Public health and security authorities
(*eg, law enforcement, border control,
customs) are linked during a suspect or
confirmed biological event
*criteria for level 4 became more stringent with
revised JEE tool
12[1to2
([)
Medical
countermeasures
and personnel
deployment
R4.1: System in place for activating and
coordinating medical countermeasures
during a public health emergency
12[1.3 to 1.7
([)
R4.2: System in place for activating and
coordinating health personnel during a
public health emergency
114
R4.3: Case management procedures
implemented for IHR relevant hazards
(R2.4 from JEE version 1)
224
Risk
communications
R5.1: Risk communication systems for
unusual/unexpected events and
emergencies
12[2.4 to 3
([)
R5.2: Internal and partner coordination for
emergency risk communication
334
R5.3: Public communication for
emergencies
23[
R5.4: Communication engagement with
affected communities
334
R5.5: Addressing perceptions, risky
behaviors, and misinformation
34[
IHR-Related Hazards and Points of Entry
Points of entry POE.1: Routine capacities established at
points of entry
13[1to3
([)
POE.2: Effective public health response at
points of entry
114
Chemical events CE.1: Mechanisms established and
functioning for detecting and responding
to chemical events or emergencies
1141.5 to 1.5
(4)
CE.2: Enabling environment in place for the
management of chemical events
224
Radiation
emergencies
RE.1: Mechanisms established and
functioning for detecting and responding
to radiological and nuclear emergencies
3343to3
(4)
RE.2: Enabling environment in place for the
management of radiological and nuclear
emergencies
334
Note: 4indicates no change; [indicates an increase; Yindicates a decrease.
a
JEE Scoring: 1, no capacity; 2, limited capacity; 3, developed capacity; 4, demonstrated capacity; 5, sustainable capacity.
Abbreviations: AMR, antimicrobial resistance; FAO, Food and Agriculture Organization of the United Nations; IHR, International Health
Regulations; JEE, Joint External Evaluation; OIE, World Organisation for Animal Health; WHO, World Health Organization.
Volume 20, Number 1, 2022 79
Furthermore, multisectoral efforts on response to reported
food-related outbreaks have been ad hoc, while recommen-
dations in the approved National Policy on Food Safety
and Implementation Strategy
48
have been partially imple-
mented. In the immunization technical area, the score for
measles immunization coverage decreased from 3 to 2,
based on more recent coverage survey data rather than the
use of administrative data, which was used in the original
JEE. Immunization-related challenges are being addressed
through the implementation of a comprehensive approach
including: (1) nationwide and targeted measles vaccination
campaigns (with the goal of 84.5% national coverage); (2)
using community health influencers, promoters, and ser-
vices; (3) leveraging the newly established Basic Healthcare
Provision Fund to improve access to routine immuniza-
tion via primary healthcare services; (4) coordinating the
equitable improvement of immunization coverage through
a National Emergency Routine Immunization Coordina-
tion Centre; and (5) the approval of a cold chain equip-
ment optimization plan to be implemented by the
government of Nigeria with funding support from Gavi,
the Vaccine Alliance.
Detect
Most indicators in the Detect core area recorded an in-
crease in scores. Nigeria’s highest scores were 4 for D1.1
(laboratory testing for detection of priority diseases) and D3.1
(systems for efficient reporting externally); however, Nigeria’s
previous high score was 4 for D4.4 (field epidemiology
training program or other applied epidemiology training
program is in place), which decreased to 3 in the mid-
term JEE. One new indicator, D4.3 (in-service trainings are
available), was added to the human resources technical area.
Laboratory technical area scores increased for 3 of the
4 indicators: D1.1 (laboratory testing for detection of pri-
ority diseases) increased from 3 to 4, D1.2 (specimen re-
ferral and transport system) increased from 1 to 2, and
D1.3 (effective national diagnostic network) increased from
2 to 3. However, there was no evidence that quality im-
provement guidance documents were followed or available.
Sample transportation between levels was poorly coordi-
nated and ad hoc, laboratory information management
systems are not available, and overall, there was a poor gov-
ernance structure in the laboratory system. In the sur-
veillance technical area, scores increased from 2 to 3 for
indicator D2.2 (use of electronic tools) and decreased from
3 to 2 for D2.1 (surveillance systems). The decrease in
D2.1 was ascribed to the requirement for indicator-based
Table 2. Overall Change in Nigeria’s JEE Scores
by Technical Area, 2017 to 2019
Change
a
Technical Area
Number of
Technical Areas
Increased
b
National legislation, policy,
and financing
Biosafety and biosecurity
National laboratory system
Reporting
Emergency preparedness
Emergency response operations
Linking public health and
security agencies
Medical countermeasures
Risk communication
Point of entry
Zoonotic disease
11
No change IHR coordination,
communication, and advocacy
Antimicrobial resistance
Surveillance
Chemical events
Radiation emergencies
5
Decreased Food safety
Immunization
Human resources
3
a
Average score per technical area.
b
Technical areas increased but have not reached the highest scoring
level of 5 (sustainable capacity).
Abbreviation: IHR, International Health Regulations.
Table 3. Key National Priorities in Nigeria Following the Midterm JEE
National Priorities Description
1 Budgetary allocation Increasing domestic budget allocation, release, and tracking for health security
Harnessing resources in the Regional Disease Surveillance Systems Enhancement project across
government ministries, departments, and agencies
2 Improved coordination Implementing activities in technical areas, which requires leadership from the highest level
Improving coordination across government ministries, departments, and agencies and working
closely with the national IHR Focal Point (Nigeria Centre for Disease Control)—legally
defined after the JEE in 2017
Training and ensuring availability of dedicated staff to prioritize activities identified in the
NAPHS for government ministries, departments, and agencies
3 Implementation
and monitoring
Provision of oversight by the honourable ministers in relevant government ministries,
departments, and agencies (health, agriculture, and environment) through request for IHR/
NAPHS implementation updates on a frequent basis
Abbreviations: IHR, International Health Regulations; JEE, Joint External Evaluation; NAPHS, National Action Plan for Health Security.
REVIEWING HEALTH SECURITY CAPACITIES IN NIGERIA
80 Health Security
surveillance and event-based surveillance at the subnational
level. Challenges in this technical area included minimal
involvement of private health facilities in reporting sur-
veillance data and a nonoperational interoperability system
at national and subnational levels. Indicator D4.3 (in-ser-
vice trainings are available) attained a score of 3 while there
was a decrease in scoring from 3 to 2 for indicator D4.4
(field epidemiology training program or other applied ep-
idemiology training program is in place). Key challenges
included the inability to continue the Nigeria Field Epi-
demiology and Laboratory Training Program basic level
training, having sufficient public health workforce at sub-
national level, and the creation of an incentivized career
path for already trained personnel. These challenges are
in addition to difficulties experienced coordinating the
cadre of human and animal healthcare counterparts to es-
tablish unified human resources competencies.
Respond
Indicators in this core area recorded an increase in scores
between the 2 assessments. Scores increased either from 1 to
2, or 2 to 3. Indicators R2.3 (emergency exercise manage-
ment program) and R5.5 (addressing perceptions, risky
behaviors, and misinformation) increased from 3 to 4. In
the emergency preparedness technical area, the score in-
creased from 2 to 3 for indicator R1.1 (strategy emergency
risk assessments conducted and emergency resources iden-
tified and mapped) and remained at 1 for R1.2 (national
multisectoral, multihazard emergency preparedness mea-
sures, including emergency response plans, are developed,
implemented, and tested). The scores of all 3 indicators in
the emergency response operations technical area increased
between the assessments, including from 3 to 4 for indi-
cator R2.3 (emergency exercise management program).
Scores increased from 2 to 3 for the remaining 2 indicators:
R2.1 (emergency response coordination) and R2.2 (emer-
gency operation center capacities, procedures, and plans).
Improvement in scoring was a result of the implementation
of key recommendations from the 2017 JEE, especially
around conducting joint simulation exercises between pub-
lic health and security agencies. In addition, establishing
public health emergency operation centers across several
states in Nigeria provided a platform for improved emer-
gency response coordination to other disease outbreaks.
Challenges in this technical area include limited staff and
operational funding at the subnational level for the emer-
gency operations centers. The coordination mechanisms
also need to be strengthened as there was no evidence these
emergency operation centers were activated within the re-
quired 120 minutes of notification of a public health event.
Scoring for indicator R3.1 (public health and security
authorities are linked during a suspect or confirmed bio-
logical event) increased from 1 to 2. A major challenge in
this technical area was the inability to conduct capacity-
strengthening simulation exercises for staff across MDAs
despite identifying and establishing points of contact across
relevant civil MDAs and security formations for the pro-
posed engagements. In the medical countermeasures and
personnel deployment technical area, only 1 of 3 indicators
increased in scoring: R4.1 (system in place for activating
and coordinating medical countermeasures during a public
health emergency) increased from 1 to 2.
Of the 5 indicators in the risk communications techni-
cal area, 3 indicators showed increased scores. Indicator
R5.5 (addressing perceptions, risky behaviors, and misin-
formation) increased from 3 to 4, reflecting the use of
the connect center to collect information on rumors and
misinformation. Data from these platforms supported the
development of targeted messaging and risk communica-
tion approaches to managing rumors during outbreaks.
Scores increased from 1 to 2 for the remaining 2 indicators:
R5.1 (risk communication systems for unusual/unexpected
events and emergencies) and R5.3 (public communication
for emergencies). Challenges in this technical area inclu-
ded limited funding for risk communications activities, lack
of a monitoring and evaluation framework, and lack of a
coordination structure for risk communications at the sub-
national levels.
Other IHR-Related Hazards
and Points of Entry
Scores remained the same for all indicators except POE.1
(routine capacities established at points of entry), which
increased from 1 to 3. Challenges identified in this tech-
nical area included inadequate national legislative backing
for port health services at points of entry, limited cross-
border collaboration at ground crossings, and suboptimal
all-hazards coordination at points of entry—chemical and
radiation components in existing plans and protocols were
not all-inclusive or robust enough.
Discussion
Countries should continuously conduct self-appraisal ex-
ercises to determine their level of pandemic preparedness
and develop realistic plans to strengthen health security core
capacities, especially during periods between events. These
self-appraisals include system assessments (eg, JEE and
State Party Self-Assessment Annual Reporting) and real-
world events including after-action reviews. Nigeria has
conducted after-action reviews for previous outbreaks,
49,50
which helped identify major gaps in preparedness and re-
sponse to outbreaks. Both assessments in 2017 and 2019
suggest that more work is required
27,51
to strengthen health
security capacities in Nigeria.
The country-led assessment provided an opportunity to
reenergize high-level cross-government political commit-
ment to strengthening Nigeria’s health security capacities.
Furthermore, the assessment enabled the integration of the
lessons from previous outbreaks into the larger operational
planning process, prioritizing recent and relevant risks, and
FASOMINU ET AL
Volume 20, Number 1, 2022 81
institutionalizing the recommendations from such exer-
cises. Through these reviews, activities such as the estab-
lishment of state public health emergency operation centers
were introduced and have proven to be of value in Nigeria’s
COVID-19 response coordination. Specifically, the public
health emergency operation centers have continued to serve
as a useful framework for driving the subnational level re-
sponse to the COVID-19 pandemic and as a common
rallying point for a multisectoral response by stakehold-
ers at the strategic, tactical, and operational levels. The
country-led assessment reflected a commitment to collec-
tive action, self-improvement, learning, and transparency.
The country was able to leverage the momentum garnered
across key IHR stakeholders to review the status of the
activities prioritized in the NAPHS and to self-appraise its
performance. This was done while providing data repre-
sentative of the implementation status of the World Bank-
funded Regional Disease Surveillance Systems Enhance-
ment project, as part of midpoint evaluations for the
country and the World Bank.
Implementing the IHR is not the sole responsibility of
the Nigeria Ministry of Health
33
or its implementing
agencies. Although a nascent national public health insti-
tute, the Nigeria Centre for Disease Control organized and
galvanized support for strengthening health security by
bringing key stakeholders together from different sectors
like the experience during the 2017 JEE. Consequently,
MDAs—especially in health, agriculture, and environment—
have continued to work in a continuum irrespective of the
mandate of the supervising parent ministry. Sustaining this
work will be important especially through the newly
formed IHR interministerial technical working group
tasked with ensuring ongoing coordination of IHR activi-
ties across the MDAs.
The midterm assessment was anchored on transparency,
peer-to-peer reviews, and trust—tenets that are core to the
JEE. The JEE second edition tool,
43
now more specific (eg,
emphasizing subnational core capacities and spotlighting
the animal health sector), enabled the collection of new in-
depth information on the status of key technical areas while
retaining the integrity of the original tool. Updated and
more relevant baseline scores were obtained as a result. Due
to the integration with operational planning, the exercise
provided clear direction in identifying high-priority activ-
ities to be implemented in 2020. The use of the WHO
benchmarks tool by the team of evaluators, subject matter
experts, and in-country technical leads was of immense
value in helping to reach consensus on priorities for im-
plementation for each technical area based on the country’s
assessed JEE scores. The benchmarks are a useful supple-
ment to the existing IHR monitoring and evaluation
framework; they are not an assessment tool but enabled easy
reference to prioritize actions to attain the next capacity
level of the JEE. In a few technical areas, where the im-
plementation of activities had just commenced or were still
ongoing since 2017, scoring did not change substantially
because all the prescriptions per the benchmark tool have
not been attained. These ongoing activities are noted as
comments in the final report.
52
With the revised, more
stringent tool, performing a midterm assessment may make
it more challenging for countries to demonstrate progress
after the initial JEE; the new scores might not reflect the
amount of progress made in a single sector or technical area,
but may reflect some progress that is more conservatively
measured and robust. This challenge was limited to only a
few indicators, however, and such nuances should be well
communicated and documented. Using this approach, the
scores were more reflective of actual progress and more
objective.
The JEE, and its approach, is one of several efforts to
spotlight the need for better preparedness and ensure
compliance with IHR by countries signatory to it. Al-
though the JEE was not developed to compare pandemic
preparedness across countries, with the COVID-19 pan-
demic, there has been more focus on the JEE’s utility to
better understand response indicators such as time-to-first-
case detection.
53
The JEE was designed for epidemic-prone
diseases and not necessarily pandemics. A major distinction
between both public health events is that epidemics are
expected to be primarily managed by the health sector,
whereas pandemics require a whole-of-society approach
including cutting through bureaucratic red tape across
different levels of society. It is also evident that the JEE does
not measure critical indicators on pandemic preparedness,
such as health system resilience.
54
However, recognizing
this limitation has helped guide and support advocacy ef-
forts for strengthening health security.
55
The JEE has
highlighted that health security capacity may not neces-
sarily translate to having the capability to respond to public
health events. Such capabilities can only be observed during
real-world events—a gap that after-action reviews
56,57
have
been designed to fill in addition to other IHR monitor-
ing and evaluation framework components. Regardless, the
JEE remains critical to help structure national action
planning for health security, providing a common language
and framework for countries to work toward. In Nigeria,
the midterm JEE was carried out because the country had
made substantial progress in the 2 years since the first JEE.
The midterm review was a useful process to assess this prog-
ress, define operational priorities, and integrate with
country planning cycles, which was not explicitly part of the
first JEE process. As such, countries can decide how and
when similar assessments can be conducted, once or twice a
year, as part of a continuous improvement process. The
2019 midterm JEE assessment in Nigeria highlighted where
progress had been made since 2017 and enabled repri-
oritization of systems strengthening efforts. An important
point to also consider going forward is that generalization of
the findings from the initial JEE—by extrapolating pre-
paredness scores to all administrative entities—could be
misleading, especially in countries with autonomous subna-
tional governing structures like in Nigeria.
REVIEWING HEALTH SECURITY CAPACITIES IN NIGERIA
82 Health Security
Nigeria is governed through a federal system. The con-
stitution provides for a substantial degree of autonomy
across the 3 tiers of government—federal, state, and local.
There are 36 states each with their own budget, priorities,
and constitutional authority for health sector interventions.
Participation by state epidemiologists and their feedback
provided for a balanced view on potential IHR imple-
mentation challenges at the subnational level, from the
states and local government areas with an acknowledgment
of these limitations in the 1999 Constitution of the Federal
Republic of Nigeria (as amended).
58
Within Nigeria’s con-
stitution, there are limitations around the development
and review of legislation. Specifically, only the federal gov-
ernment can legislate and establish laws on items on the
exclusive list, while federal and state governments can es-
tablish laws on items on the concurrent list. Where there
is an existing federal law, however, states must defer to the
former. Items on the residual list are solely the respon-
sibility of state governments. Public health (eg, disease
detection, surveillance, reporting, coordination) is on the
residual list.
59
The power to establish legislation requires
improved involvement of the subnational level on assess-
ments such as the JEE and subsequent planning for invest-
ments in health security. With Nigeria’s federated nature
of governance, geographic and bureaucratic distance from
the frontlines to the center of governance,
60
the role of the
state epidemiologists, and contribution during the mid-
term JEE, as well as other personnel at the subnational
level
45
are critical to strengthening health security. This was
evident with scoring in the surveillance technical area, for
instance, which required commensurate development of
similar capacities at the subnational level. This type of lim-
itation has spurred conversations on the importance of as-
sessments of health security capacities at the subnational
level. The need for this type of granular assessment is even
more evident with the varied response to the COVID-19
pandemic in Nigeria and role of key personnel—especially
at the subnational level. As such, subsequent JEEs or health
security assessments need to capture the nuances on pre-
paredness within these entities versus having a national rep-
resentative scoring. This may be misleading, giving a false
sense of preparedness. We recommend that countries en-
deavor to have representation from stakeholders at the
subnational level during such discourse, to provide insights
from their unique experience working at that level. Fur-
thermore, countries can domesticate the JEE tool to better
capture more qualitative and formative information that
existing health information systems cannot unearth. This
can help to identify specific areas that require additional
efforts for strengthening, within the confines of the consti-
tution or other existing laws.
Assessing health security capacities at the subnational
level can be expensive and time-consuming. However, sev-
eral granular assessments have been proposed using data
that already exist in health information and disease sur-
veillance systems. Examples include the timeliness mile-
stones and metrics.
61
Standardized outbreak milestones
enable countries to define and calculate relevant timeliness
metrics, designed around milestones, to address their own
needs. Milestones can include the dates when a country
predicts, detects, verifies, and responds to an outbreak;
notifies authorities; and launches a multisectoral investi-
gation, conducts laboratory tests, implements control mea-
sures, and informs the public. A timeliness metric is then
measured as the time interval between 2 relevant outbreak
milestones—and importantly, can be calculated at the
subnational level. WHO has used a combination of these
and other indicators, such as the State Party Self-Assess-
ment Annual Reporting tool indicators for preparedness
capacity, and immunization indicators to capture real-
world event data in its ‘‘triple billion’’ methods and make a
distinction between measures of capacity and capability.
62
Other measures include a new global target of 7-1-7,
whereby every suspected outbreak is identified within
7 days of emergence, reported to public health authorities
with initiation of investigation and response efforts within
1 day, and effectively responded to—as defined by objective
benchmarks—also within 7 days.
61
Each of these can be
applied at both country and subnational levels to entrench
a transparent framework for assessing outbreak response
capabilities and identify gaps in health security capacities
within the framework of health systems strengthening.
One of the objectives of the midterm JEE was to inform
the review of the country’s NAPHS. With the review, it was
evident that ownership and accountability were weak
despite the availability of performance management tools—
a monitoring and evaluation framework and an implemen-
tation tracker. Other issues identified were: (1) the NAPHS
monitoring and evaluation framework was not sufficiently
robust to track output and outcomes and was laden with
numerous activities that needed to be pruned
36
; (2) elec-
tronic tools (eg, NAPHS tracker) developed to track the
status of implementation were difficult to implement es-
pecially where the legislation, coordination, communi-
cation, review, and provision of feedback across various
IHR implementing MDAs was weak and suboptimal; (3)
NAPHS and related plans need to be created for shorter
periods (eg, annually or every 2 years); (4) subsequent
planning needs to depend on the outcome of the evaluation
of activities previously implemented
36
; and (5) strategic
realignment of priority activities can help maximize already
existing funding sources (eg, the Regional Disease Surveil-
lance Systems Enhancement project) to support strength-
ening health security capacities. In addition, the NAPHS
has too many, often ambitious, prioritized annual activities.
These activities are not entirely included in the annual work
plans of the MDAs and therefore often have no budget.
Hence implementation was severely hampered. Of the
634 planned activities for fiscal year 2019, only 4% were
completed by responsible MDAs. Implementation status of
many other planned activities was either unknown, past
due, or not updated. IHR participating or implementing
FASOMINU ET AL
Volume 20, Number 1, 2022 83
MDAs also had limited understanding of their roles as it
relates to IHR. This further compounded the implemen-
tation and follow-through of prioritized activities—even
when funding was available.
Poorly executed NAPHS activities by countries may have
also contributed to the weak response to COVID-19 across
countries, as gaps identified after the 2017 JEE were not
addressed. Coordination among relevant MDAs with a role
in health security can help improve the implementation of
activities that address health security gaps. In Nigeria, fol-
lowing the midterm JEE, the Nigeria Centre for Disease
Control led and advocated for the establishment of an in-
terministerial technical working group for IHR. This was,
with equitable representation, from relevant MDAs to drive
and sustain the implementation of health security activities,
and champion advocacy efforts as required. A key requi-
rement for membership in the technical working group was
for members to be capable of making decisions or influ-
encing decision makers. Although the Nigeria Centre for
Disease Control is the national IHR Focal Point, within the
federated structure in Nigeria, the various MDAs are in-
dependent and thus need to be mutually accountable with a
governance model that enables this alignment. As such,
members from the MDAs developed terms of reference for
the national technical working group to describe their roles
and responsibilities, including reporting processes. The
NAPHS tracker was developed to support the reporting
process across the MDAs and foster the desire of the
technical working group to institutionalize its mutual ac-
countability. Challenges with deployment of the NAPHS
tracker have been discussed here and elsewhere.
36
Conclusion
Although evidence suggests that the IHR monitoring and
evaluation framework, and particularly the JEE indicators,
do not provide a complete assessment of pandemic pre-
paredness,
53
we found that the framework provides readily
available tools that can be deployed to help identify gaps in
preparedness. Assessments such as this are also equally
important and needed by state parties to guide strategic
development of operational plans (not just the NAPHS) for
prioritizing the most immediate health security needs.
Based on these assessments, state parties can develop ho-
listic and realistic plans to further strengthen health security
and build requisite core capacities as stipulated in IHR.
Despite the challenges with the JEE and its representation
of preparedness before the COVID-19 pandemic, it has
helped to improve understanding of the status of pandemic
preparedness across countries.
27
State parties need to con-
sistently and intentionally invest in pandemic prepared-
ness, and strengthening health security should be seen as a
collaboration beyond the ministries of health alone.
63
It is now more critical that preparedness activities are
led by countries, based on the nuances and peculiarities
of governance and governing structures. This will help
foster sustainability and ownership of developed plans,
which need to be backed by consistent funding and
anchored on multisectoral engagement across various sub-
national entities and relevant MDAs—led by a national
public health institute—for a safer world.
Acknowledgments
The authors would like to acknowledge the active partici-
pation of national experts in preparing for the midterm JEE
mission. We also recognize the invaluable partnerships with
governments including the governments of the United
Kingdom and the United States for providing technical
experts for this country-led review process; with other in-
tergovernmental organizations, particularly FAO, OIE,
West Africa Health Organization, Resolve to Save Lives,
World Bank, Georgetown University, Public Health
England, US Centers for Disease Control and Prevention,
Pro-Health International, African Field Epidemiology
Network, Volte Health, and University of Maryland, Bal-
timore for their contribution of expertise. We appreciate
the financial support provided by Resolve to Save Lives and
Public Health England for this activity and the WHO
Nigeria Country Office for technical, planning, and fi-
nancial support. The authors would like to acknowledge
the continuing support and commitment of all of these to
the implementation and principles of the IHR.
References
1. de Bengy Puyvalle
´e A, Kittelsen S. ‘‘Disease knows no bor-
ders’’: pandemics and the politics of global health security.
In: Bjørkdahl K, Carlsen B, eds. Pandemics, Publics, and
Politics: Staging Responses to Public Health Crises. Singapore:
Palgrave Pivot; 2019:59-73.
2. Ericsson CD, Steffen R, Isaa
¨cson M. Viral hemorrhagic fever
hazards for travelers in Africa. Clin Infect Dis. 33(10):1707-
1712.
3. Okunromade OF, Lokossou VK, Anya I, et al. Performance
of the public health system during a full-scale yellow fever
simulation exercise in Lagos State, Nigeria, in 2018: how
prepared are we for the next outbreak. Health Secur. 2019;
17(6):485-494.
4. Zumla A, Dar O, Kock R, et al. Taking forward a
‘One Health’ approach for turning the tide against the
Middle East respiratory syndrome coronavirus and other
zoonotic pathogens with epidemic potential. Int J Infect Dis.
2016;47:5-9.
5. Ruan S, Wang W, Levin SA. The effect of global travel on
the spread of SARS. Math Biosci Eng. 2006;3(1):205-218.
6. Yang S, Shi Y, Lu H, et al. Clinical and CT features of early
stage patients with COVID-19: a retrospective analysis of
imported cases in Shanghai, China. Eur Respir J. 2020;55(4):
2000407.
7. Wu J, Liu J, Zhao X, et al. Clinical characteristics of
imported cases of coronavirus disease 2019 (COVID-19) in
Jiangsu Province: a multicenter descriptive study. Clin Infect
Dis. 2020;71(15):706-712.
REVIEWING HEALTH SECURITY CAPACITIES IN NIGERIA
84 Health Security
8. Ha
ˆncean MG, Perc M, Lerner J. Early spread of COVID-19
in Romania: imported cases from Italy and human-to-
human transmission networks. R Soc Open Sci. 2020;7(7):
200780.
9. Craig AT, Heywood AE, Hall J. Epidemiology and infection
risk of COVID-19 importation to the Pacific islands through
global air travel. Epidemiol Infect. 2020;148:e71.
10. Huber C, Finelli L, Stevens W. The economic and social
burden of the 2014 Ebola outbreak in West Africa. J Infect
Dis. 2018;218(suppl 5):S698-S704.
11. World Bank. The Economic Impact of the 2014 Ebola Epi-
demic: Short- and Medium-Term Estimates for West Africa.
Washington, DC: World Bank; 2014.
12. Shuaib F, Gunnala R, Musa EO, et al. Ebola virus disease
outbreak - Nigeria, July-September 2014. MMWR Morb
Mortal Wkly Rep. 2014;63(39):867-872.
13. Nwachukwu W, Yusuff H, Nwangwu U, et al. The response
to re-emergence of yellow fever in Nigeria, 2017. Int J Infect
Dis. 2020;92:189-196.
14. Monath TP, Vasconcelos PFC. Yellow fever. J Clin Virol.
2015;64:160-173.
15. Akpede GO, Asogun DA, Okogbenin SA, Okokhere PO.
Lassa fever outbreaks in Nigeria. Expert Rev Anti Infect Ther.
2018;16(9):663-666.
16. Roberts L. Nigeria hit by unprecedented Lassa fever out-
break. Science. 2018;359(6381):1201-1202.
17. Maxmen A. Deadly Lassa-fever outbreak tests Nigeria’s
revamped health agency. Nature. 2018;555(7697):421-
422.
18. Nnadi C, Oladejo J, Yennan S, et al. Large outbreak of
neisseria meningitidis Serogroup C — Nigeria, December
2016–June 2017. MMWR Morb Mortal Wkly Rep. 2017;
66(49):1352-1356.
19. Dalhat MM, Isa AN, Nguku P, et al. Descriptive charac-
terization of the 2010 cholera outbreak in Nigeria. BMC
Public Health. 2014;14:1167.
20. Elimian KO, Musah A, Mezue S, et al. Descriptive epide-
miology of cholera outbreak in Nigeria, January-November,
2018: implications for the global roadmap strategy. BMC
Public Health. 2019;19(1):1264.
21. Hofstetter AM, DuRivage N, Vargas CY, et al. Text message
reminders for timely routine MMR vaccination: a random-
ized controlled trial. Vaccine. 2015;33(43):5741-5746.
22. Adegboye O, Adekunle A, Gayawan E. Early transmission
dynamics of novel coronavirus (COVID-19) in Nigeria. Int J
Environ Res Public Health. 2020:17(9):3054.
23. Marcantonio M, Rizzoli A, Metz M, et al. Identifying the
environmental conditions favouring West Nile Virus out-
breaks in Europe. PLoS One. 2015;10(3):e0121158.
24. Bezirtzoglou C, Dekas K, Charvalos E. Climate changes,
environment and infection: facts, scenarios and growing
awareness from the public health community within Europe.
Anaerobe. 2011;17(6):337-340.
25. Lau CL, Smythe LD, Craig SB, Weinstein P. Climate
change, flooding, urbanisation and leptospirosis: fuelling the
fire? Trans R Soc Trop Med Hyg. 2010;104:631-638.
26. Poletto, Gomes MF, Pastore y Piontti A, et al. Assessing the
impact of travel restrictions on international spread of the
2014 west African Ebola epidemic. Euro Surveill. 2014;
19(42):20936.
27. Shahpar C, Lee CT, Wilkason C, Buissonnie
`re M,
McClelland A, Frieden TR. Protecting the world from in-
fectious disease threats: now or never. BMJ Glob Health.
2019;4(4):e001885.
28. World Health Organization. World Health Assembly adopts
new International Health Regulations. Published May 23,
2005. Accessed October 29, 2021. https://apps.who.int/
mediacentre/news/releases/2005/pr_wha03/en/index.html
29. Talisuna A, Yahaya AA, Rajatonirina SC, et al. Joint external
evaluation of the International Health Regulation (2005)
capacities: current status and lessons learnt in the WHO
African region. BMJ Glob Health. 2019;4(6):e001312.
30. World Health Organization (WHO). International Health
Regulations (2005): IHR Monitoring and evaluation Frame-
work. Geneva: WHO; 2018. Accessed December 16, 2021.
https://www.who.int/publications/i/item/international-health-
regulations-(-2005)-ihr-monitoring-and-evaluation-framework
31. Bell E, Tappero JW, Ijaz K, et al. Joint external evaluation—
development and scale-up of global multisectoral health
capacity evaluation process. Emerg Infect Dis. 2017;23(13):
S33-S39.
32. Lee CT, Katz R, Eaneff S, Mahar M, Ojo O. Action-based
costing for national action plans for health security: accel-
erating progress toward the International Health Regulations
(2005). Health Secur. 2020;18(S1):S53-S63.
33. World Health Organization (WHO). Implementation of
the International Health Regulations (2005): report of the
review committee on second extensions for establishing na-
tional public health capacities and on IHR implementation.
Sixty-Eighth World Health Assembly Provisional Item 15.3.
Published March 27, 2015. Accessed December 16, 2021.
https://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_22Add1-
en.pdf
34. Lee CT, Frieden T. Why even well-prepared countries failed
the pandemic test. Foreign Affairs. March 29, 2021. Accessed
September 5, 2021. https://www.foreignaffairs.com/articles/
united-states/2021-03-29/why-even-well-prepared-countries-
failed-pandemic-test?utm_medium=promo_email&utm_
source=lo_flows&utm_campaign=registered_user_welcome&
utm_term=email_1&utm_content=20210905
35. World Health Organization (WHO). Joint External Eva-
luation of IHR Core Capacities of the Federal Republic of
Nigeria. Geneva: WHO; 2017. Accessed September 19,
2020. https://www.who.int/publications/i/item/WHO-
WHE-CPI-REP-2017.46
36. Ojo OE, Dalhat M, Garfield R, et al. Nigeria’s Joint External
Evaluation and National Action Plan for Health Security.
Health Secur. 2020;18(1):16-20.
37. World Health Organization. Strategic Partnership for
Health Security and Emergency Preparedness (SPH) Portal.
Accessed December 16, 2021. https://extranet.who.int/sph/
home
38. Mghamba JM, Talisuna AO, Suryantoro L, et al. Developing
a multisectoral National Action Plan for Health Security
(NAPHS) to implement the International Health Regula-
tions (IHR 2005) in Tanzania. BMJ Glob Health. 2018;3(2):
e000600.
39. Nigeria Centre for Disease Control. Heads of 19 agencies
affirm support for the new National Action Plan for Health
Security. Published December 17, 2018. Accessed December
FASOMINU ET AL
Volume 20, Number 1, 2022 85
16, 2021. https://ncdc.gov.ng/news/159/heads-of-19-agen
cies-affirm-support-for-the-new-national-action-plan-for-health-
security
40. Nigeria Centre for Disease Control (NCDC). National
Action Plan for Health Security Federal Republic of Nigeria
(2018-2022). Abuja: NCDC; 2018. Accessed December
2021, 2021. https://extranet.who.int/sph/sites/default/files/
document-library/document/Nigeria%20National%20Action%
20Plan%20for%20Health%20Security.pdf
41. The World Bank. Regional Disease Surveillance Systems
Enhancement (REDISSE). Accessed December 16, 2021.
https://projects.worldbank.org/en/projects-operations/project-
detail/P154807
42. Nigeria Centre for Disease Control. Press release – Nigeria
holds mid-term Joint External Evaluation of International
Health Regulations. Published November 22, 2019. Ac-
cessed December 16, 2021. https://ncdc.gov.ng/news/204/
press-release—nigeria-holds-mid-term-joint-external-evalua
tion-of-international-health-regulations
43. World Health Organization (WHO). Joint External
Evaluation Tool, Second Edition. International Health Reg-
ulations (2005). Geneva: WHO; 2019. Accessed September
19, 2020. https://www.who.int/publications/i/item/9789241
550222
44. World Health Organization (WHO). WHO Benchmarks for
International Health Regulations (IHR) Capacities. Geneva:
WHO; 2019. Accessed September 19, 2020. https://www.
who.int/publications/i/item/9789241515429
45. Atanda A, Agogo E, Fasominu K, et al. After-action reviews
as a best practice tool for evaluating the response to ur-
ban disease outbreaks in Nigeria. In: Katz R, Boyce M, eds.
Inoculating Cities: Case Studies of Urban Pandemic Pre-
paredness. Cambridge, MA: Academic Press; 2021:61-77.
46. Federal Republic of Nigeria. Nigeria Public Health Act bill,
2013. Accessed January 5, 2022. https://drive.google.com/
file/d/1jlZ8yX0KpYe1imeZgijoKzU7V9sLJnbF/view?usp=
sharing
47. Federal Republic of Nigeria. National Health Act, 2014.
Federal Republic of Nigeria Official Gazette. 101(145):A139-
A172. Accessed January 5, 2022. https://nigeriahealth
watch.com/wp-content/uploads/bsk-pdf-manager/2018/07/
01_-Official-Gazette-of-the-National-Health-Act-FGN.pdf
48. Federal Ministry of Health (FMOH). National Policy on
Food Safety and Its Implementation Strategy. Abuja: FMOH;
2014. Accessed January 5, 2022. https://drive.google.com/file/
d/0B1DAmtM1BcbMczJtRDBnczlxc00/view?resourcekey=0-
Gfd5O5dfyUMEWxyMYg4qvg
49. Eteng WE, Mandra A, Doty J, et al. Notes from the field:
responding to an outbreak of monkeypox using the One
Health approach - Nigeria, 2017-2018. MMWR Morb
Mortal Wkly Rep. 2018;67(37):1040-1041.
50. World Health Organization. After Action Review (AAR) –
Nigeria. Accessed April 18, 2021. https://extranet.who.int/
sph/after-action-review?region=All&country=232
51. Prevent Epidemics. Nigeria. Accessed September 19, 2020.
https://preventepidemics.org/countries/nga/
52. Nigeria Centre for Disease Control (NCDC). Country-Led
Midterm Joint External Evaluation of IHR Core Capacities.
Abuja, Nigeria: NCDC; 2020. Accessed September 19,
2020. https://ncdc.gov.ng/themes/common/docs/protocols/
119_1581414518.pdf
53. Haider N, Yavlinsky A, Chang YM, et al. The Global Health
Security Index and Joint External Evaluation score for health
preparedness are not correlated with countries’ COVID-19
detection response time and mortality outcome. Epidemiol
Infect. 2020;148:e210.
54. Razavi A, Erondu N, Okereke E. The Global Health Security
Index: what value does it add? BMJ Glob Health. 2020;5(4):
e002477.
55. Kandel N, Sreedharan R, Chungong S, et al. Joint external
evaluation process: bringing multiple sectors together for
global health security. Lancet Glob Health. 2017;5(9):e857-
e858.
56. Mayigane LN, de Va
´zquez CC, Vente C, et al. The necessity
for intra-action reviews during the COVID-19 pandemic.
Lancet Glob Health. 2020;8(12):e1451-e1452.
57. Stoto MA, Nelson C, Piltch-Loeb R, Mayigane LN, Copper
F, Chungong S. Getting the most from after action re-
views to improve global health security. Global Health. 2019;
15(1):58.
58. Federal Republic of Nigeria. Constitution of the Federal
Republic of Nigeria 1999. Abuja: Federal Republic of Nigeria;
1999. Accessed December 16, 2021. https://publicofficials
financialdisclosure.worldbank.org/sites/fdl/files/assets/law-lib
rary-files/Nigeria_Constitution_1999_en.pdf
59. Onyemelukwe C. IHR Implementation in Nigerian Law:
Mapping of Legal Authorities and Analysis of Legislation at
Federal Level. Abuja: Nigeria Centre for Disease Control;
2020. Accessed August 10, 2021. https://ncdc.gov.ng/
themes/common/docs/protocols/116_1580654680.pdf
60. Okotoni O. Problems and prospects of Nigerian bureau-
cracy. J Soc Sci. 2017;7(3):223-229.
61. Frieden TR, Lee CT, Bochner AF, Buissonnie
`re M,
McClelland A. 7-1-7: an organising principle, target, and
accountability metric to make the world safer from pan-
demics. Lancet. 2021;398(10300):638-640.
62. World Health Organization (WHO). Thirteenth General
Programme of Work (GPW13): Methods for Impact Mea-
surement. Geneva: WHO; 2020. Accessed December 16,
2021. https://www.who.int/publications/m/item/thirteenth-
general-programme-of-work-(gpw13)-methods-for-impact-
measurement
63. Raile AN, Raile ED, Post LA. Analysis and action: the po-
litical will and public will approach. Action Res. 2021;19(2):
237-254.
Manuscript received May 9, 2021;
revision returned September 17, 2021;
accepted for publication October 4, 2021.
Address correspondence to:
Olukayode Fasominu, MD, MPH
Tasingegade 29
3rd Floor, Apartment 230
Copenhagen 2100
Denmark
Email: kayfasominu@gmail.com
REVIEWING HEALTH SECURITY CAPACITIES IN NIGERIA
86 Health Security
... 15 Nigeria used a similar approach that involved joint identification of gaps and solutions to ensure collective contribution. 35 This multisectoral demonstration of interest in health security activities should be leveraged to improve sector advocacy for inclusion of activities in sector budgets and plans to foster implementation. ...
... 34 Uganda and Nigeria have indicated that bulky national action plans for health security are difficult to track even with electronic monitoring tools. 35,36 In our experience, multisectoral self-assessment operational planning that involves government leadership, selection of a small number of realistic activities, and monitoring activities routinely can strengthen capacity. Our findings are corroborated by Nigeria's recommendation to conduct country-led self-appraisals to develop feasible IHR action plans. ...
... Our findings are corroborated by Nigeria's recommendation to conduct country-led self-appraisals to develop feasible IHR action plans. 35 Self-assessments can be subject to self-reporting bias. To counter this, Uganda applied the second edition of the JEE tool, involved multiple IHR sectors and a peer consensus approach to review capacity and identify sector-specific areas for improvement. ...
Article
Full-text available
Uganda established a National Action Plan for Health Security in 2019, following a Joint External Evaluation (JEE) of International Health Regulations (2005) capacities in 2017. The action plan enhanced national health security awareness, but implementation efforts were affected by limited funding, excess of activities, and challenges related to monitoring and evaluation. To improve implementation, Uganda conducted a multisectoral health security self-assessment in 2021 using the second edition of the JEE tool and developed a 1-year operational plan. From 2017 to 2021, Uganda's composite ReadyScore improved by 20%, with improvement in 13 of the 19 technical areas. Indicator scores showing limited capacity declined from 30% to 20%, and indicators with no capacity declined from 10% to 2%. More indicators had developed (47% vs 40%), demonstrated (29% vs 20%), and sustained (2% vs 0%) capacities in 2021 compared with 2017. Using the self-assessment JEE scores, 72 specific activities from the International Health Regulations (2005) benchmarks tool were selected for inclusion in a 1-year operational plan (2021-2022). In contrast to the 264 broad activities in the 5-year national action plan, the operational plan prioritized a small number of activities to enable sectors to focus limited resources on implementation. While certain capacities improved before and during implementation of the action plan, countries may benefit from using short-term operational planning to develop realistic and actionable health security plans to improve health security capacities.
... 72 By contrast, during the mid-term JEE in 2019, epidemiologists from the federal states were also invited to participate in the process. 73 The first edition of the JEE used in 2017 in Nigeria and several other countries did not include indicators to assess subnational level capacities. The scoring of capacity across technical areas was therefore not representative of what could be obtained across Nigeria's states. ...
... This exercise involved epidemiologists from the federal states and showed differences in health security capacity at national and subnational levels. 73 Although all epidemiologists from the federal states disclosed that they had responded to previous outbreaks of Lassa virus (which is endemic in Nigeria) and the ongoing COVID-19 pandemic, none of them had established, functional, or sustainable structures in place to identify and respond to zoonotic diseases as defined in the JEE. 73 Nigeria experiences annual outbreaks of diseases of zoonotic origin including Lassa fever, yellow fever, and mpox (formerly known as monkeypox). ...
... 73 Although all epidemiologists from the federal states disclosed that they had responded to previous outbreaks of Lassa virus (which is endemic in Nigeria) and the ongoing COVID-19 pandemic, none of them had established, functional, or sustainable structures in place to identify and respond to zoonotic diseases as defined in the JEE. 73 Nigeria experiences annual outbreaks of diseases of zoonotic origin including Lassa fever, yellow fever, and mpox (formerly known as monkeypox). On the basis of a spatial modelling exercise, Nigeria has one of the highest risks of outbreaks of emerging zoonotic infectious diseases globally. ...
Article
Full-text available
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.
Article
Full-text available
The purpose of the commentary is to help advocate for countries to partake in the IAR process in the spirit of continuous collective learning and improvement for the COVID-19 preparedness and response, especially as many countries start to prepare for second waves.
Article
Full-text available
Global Health Security Index (GHSI) and Joint External Evaluation (JEE) are two well-known health security and related capability indices. We hypothesized that countries with higher GHSI or JEE scores would have detected their first COVID-19 case earlier, and would experience lower mortality outcome compared to countries with lower scores. We evaluated the effectiveness of GHSI and JEE in predicting countries' COVID-19 detection response times and mortality outcome (deaths/million). We used two different outcomes for the evaluation: (i) detection response time, the duration of time to the first confirmed case detection (from 31st December 2019 to 20th February 2020 when every country's first case was linked to travel from China) and (ii) mortality outcome (deaths/million) until 11th March and 1st July 2020, respectively. We interpreted the detection response time alongside previously published relative risk of the importation of COVID-19 cases from China. We performed multiple linear regression and negative binomial regression analysis to evaluate how these indices predicted the actual outcome. The two indices, GHSI and JEE were strongly correlated (r = 0.82), indicating a good agreement between them. However, both GHSI (r = 0.31) and JEE (r = 0.37) had a poor correlation with countries' COVID-19–related mortality outcome. Higher risk of importation of COVID-19 from China for a given country was negatively correlated with the time taken to detect the first case in that country (adjusted R2 = 0.63–0.66), while the GHSI and JEE had minimal predictive value. In the negative binomial regression model, countries' mortality outcome was strongly predicted by the percentage of the population aged 65 and above (incidence rate ratio (IRR): 1.10 (95% confidence interval (CI): 1.01–1.21) while overall GHSI score (IRR: 1.01 (95% CI: 0.98–1.01)) and JEE (IRR: 0.99 (95% CI: 0.96–1.02)) were not significant predictors. GHSI and JEE had lower predictive value for detection response time and mortality outcome due to COVID-19. We suggest introduction of a population healthiness parameter, to address demographic and comorbidity vulnerabilities, and reappraisal of the ranking system and methods used to obtain the index based on experience gained from this pandemic.
Article
Full-text available
Global Health Security Index (GHSI) and Joint External Evaluation (JEE) are two well-known health security and related capabilities indices. We hypothesized that countries with higher GHSI or JEE scores would have detected their first case earlier, and would experience lower mortality outcome compared to countries with lower scores. We evaluated the effectiveness of GHSI and JEE in predicting countries’ COVID-19 detection response times and mortality outcome (deaths/million). We used two different outcomes for the evaluation, i) detection response time, the duration of time to the first (confirmed) case detection (from 31st December 2019 to February 20th 2020 when every country’s first case was linked to travel from China) and ii) mortality outcome (deaths/million) (up until March 11th and July 1st 2020, respectively). We interpreted the detection response time alongside previously published relative risk of the importation of COVID-19 cases from China. We performed multiple linear regression and negative binomial regression analysis to evaluate how these indices predicted the actual outcome. The two indices, GHSI and JEE were strongly correlated (r= 0.82), indicating a good agreement between them. However, both GHSI (r=0.31) and JEE (r=0.37) had a poor correlation with countries’ COVID-19 related mortality outcome. Higher risk of importation of COVID-19 from China for a given country was negatively correlated with the time taken to detect the first case in that country (adjusted R2 =0.63-0.66), while the GHSI and JEE had minimal predictive value. In the negative binomial regressing model, countries’ mortality outcome were strongly predicted by the population’s age above 65 years (Incidence rate ratio [IRR]: 1.10 (95% CI: 1.01-1.21) while overall GHSI score (IRR: 1.01 (95% CI: 0.98-1.01) and JEE (IRR: 0.99 (95% CI: 0.96-1.02) were not significant predictor. GHSI and JEE had lower predictive value for detection response time and mortality outcome due to COVID-19. We suggest introduction of a population healthiness parameter, to address demographic and comorbidity vulnerabilities and reappraisal of the ranking system and methods used to obtain the index based on experience gained from this pandemic.
Article
Full-text available
We describe the early spread of the novel coronavirus (COVID-19) and the first human-to-human transmission networks, in Romania. We profiled the first 147 cases referring to sex, age, place of residence, probable country of infection, return day to Romania, COVID-19 confirmation date and the probable modes of COVID-19 transmissions. Also, we analysed human-to-human transmission networks and explored their structural features and time dynamics. In Romania, local cycles of transmission were preceded by imported cases, predominantly from Italy. We observed an average of 4.8 days (s.d. = 4.0) between the arrival to a Romanian county and COVID-19 confirmation. Furthermore, among the first 147 COVID-19 patients, 88 were imported cases (64 carriers from Italy), 54 were domestic cases, while for five cases the source of infection was unknown. The early human-to-human transmission networks illustrated a limited geographical dispersion, the presence of super-spreaders and the risk of COVID-19 nosocomial infections. COVID-19 occurred in Romania through case importation from Italy. The largest share of the Romanian diaspora is concentrated especially in the northern parts of Italy, heavily affected by COVID-19. Human mobility (including migration) accounts for the COVID-19 transmission and it should be given consideration while tailoring prevention measures.
Article
Full-text available
On 31 December 2019, the World Health Organization (WHO) was notified of a novel coronavirus disease in China that was later named COVID-19. On 11 March 2020, the outbreak of COVID-19 was declared a pandemic. The first instance of the virus in Nigeria was documented on 27 February 2020. This study provides a preliminary epidemiological analysis of the first 45 days of COVID-19 outbreak in Nigeria. We estimated the early transmissibility via time-varying reproduction number based on the Bayesian method that incorporates uncertainty in the distribution of serial interval (time interval between symptoms onset in an infected individual and the infector), and adjusted for disease importation. By 11 April 2020, 318 confirmed cases and 10 deaths from COVID-19 have occurred in Nigeria. At day 45, the exponential growth rate was 0.07 (95% confidence interval (CI): 0.05-0.10) with a doubling time of 9.84 days (95% CI: 7.28-15.18). Separately for imported cases (travel-related) and local cases, the doubling time was 12.88 days and 2.86 days, respectively. Furthermore, we estimated the reproduction number for each day of the outbreak using a three-weekly window while adjusting for imported cases. The estimated reproduction number was 4.98 (95% CrI: 2.65-8.41) at day 22 (19 March 2020), peaking at 5.61 (95% credible interval (CrI): 3.83-7.88) at day 25 (22 March 2020). The median reproduction number over the study period was 2.71 and the latest value on 11 April 2020, was 1.42 (95% CrI: 1.26-1.58). These 45-day estimates suggested that cases of COVID-19 in Nigeria have been remarkably lower than expected and the preparedness to detect needs to be shifted to stop local transmission.
Article
Full-text available
On 30 January 2020, WHO declared coronavirus (COVID-19) a global public health emergency. As of 12 March 2020, 125 048 confirmed COVID-19 cases in 118 countries had been reported. On 12 March 2020, the first case in the Pacific islands was reported in French Polynesia; no other Pacific island country or territory has reported cases. The purpose of our analysis is to show how travellers may introduce COVID-19 into the Pacific islands and discuss the role robust health systems play in protecting health and reducing transmission risk. We analyse travel and Global Health Security Index data using a scoring tool to produce quantitative estimates of COVID-19 importation risk, by departing and arriving country. Our analysis indicates that, as of 12 March 2020, the highest risk air routes by which COVID-19 may be imported into the Pacific islands are from east Asian countries (specifically, China, Korea and Japan) to north Pacific airports (likely Guam, Commonwealth of the Northern Mariana Islands or, to a less extent, Palau); or from China, Japan, Singapore, the United States of America or France to south Pacific ports (likely, Fiji, Papua New Guinea, French Polynesia or New Caledonia). Other importation routes include from other east Asian countries to Guam, and from Australia, New Zealand and other European countries to the south Pacific. The tool provides a useful method for assessing COVID-19 importation risk and may be useful in other settings.
Chapter
The International Health Regulation (IHR) monitoring and evaluation framework includes voluntary instruments such as after-action reviews (AAR) as part of a five-year global strategic plan to improve public health preparedness and response. The Nigeria Centre for Disease Control conducted three AARs post-response to multi-city outbreaks of Monkeypox, Cerebrospinal Meningitis and Lassa Fever in 2018. All outbreaks were in urban local government areas (LGA)/cities across more than 20 states lending credence to the rise of city-states as a locus of risk for infectious disease re-emergence. Aspects of modern life in urban LGAs such as encroachment of humans into new environments and destruction of forests for agriculture puts residents in close contact with wildlife and at risk for infectious disease outbreaks. This chapter discusses the usefulness of AARs as a tool for evaluating responses to urban disease outbreaks and assess preparations for future ones using an approach that combines self-evaluation and peer review complying with the recommendations of the IHR for mandatory State Parties self-assessment annual reporting. This experience helped Nigeria identify how best practices can be maintained, improved, institutionalized and shared with relevant stakeholders. The AARs also determined how actions were implemented as opposed to how they were planned, identified processes that worked and those that didn’t, determined root causes for success and failure, and finally, provided SMART corrective recommendations to improve future performance actions and to strengthen cities pandemic readiness.