FCV Health Knowledge Notes Pandemic Preparedness and Response in Fragile, Conflict and Violence (FCV) Situations Five key questions to be answered SUMMARY Robust pandemic preparedness and response is an urgent need necessary to address vulnerability and to prevent, detect and respond to an outbreak in FCV situations. It contributes to universal health security, protecting all people from threats to their health, and should be integrated in broader efforts to strengthen health systems and make them more resilient through multistakeholder coordination. WHY Invest in Source: The Guardian Q1 pandemic preparedness Health workers caring for Ebola patients are at in FCV situations? between 21 and 32 times higher risk than the general public for contracting the disease. During the 2014-2015 By definition, FCV countries have weaker performance Ebola outbreak, 881 health workers were infected and in economic management, structural policies, social 513 died. Disease outbreaks require thorough infection inclusion and equity policies, and/or public sector control measures and hazard payments to health management and institutions. The World Bank Group workers. (WBG) categorizes FCV countries as those with a Country Policy and Institutional Assessment (CPIA) Restricted access to health services and the loss of rating of 3.2 or below and/or with the presence of a UN health workers at the time of the Ebola crisis led to and/or regional peace-keeping or peace-building worsening health services delivery by 23%. This mission during the last 3 years. Pandemics likely hit the caused setbacks in routine health services for malaria, hardest on weak systems and more vulnerable tuberculosis (TB), HIV/AIDS, non-communicable populations with less protection and services. diseases (NCDs), and reproductive, maternal, neonatal and child health (RMNCH). The countries’ already The Ebola Virus Disease outbreak in 2014-2015 devastated maternal mortality increased by 38% in resulted in a total of 28,616 confirmed cases and Guinea, by 74% in Sierra Leone and by 111% in Liberia. 11,310 deaths. Its case fatality rate was around 70%. There are more than 10,000 survivors with medical The annual global cost of moderately severe to severe problems, including mental health issues, as well as pandemics is estimated to be about US$ 570 billion, or 17,300 children who lost one or both parents to the 0.7% of global income. Fragile countries are even more Ebola. acutely and disproportionately affected. The economic and fiscal impact of the Ebola outbreak In low-and middle-income countries, the cost of has outlasted the epidemiological impact due to severe preparedness is less than $1 per person per year. shocks to investment, production, and consumption. Preparing for and preventing a pandemic is the best Losses are estimated at US$2.8 billion, or the GDP loss investment the international community can make for of US$125 per person in Guinea, Liberia and Sierra global public health. Leone. 1 Sources: The Guardian, The World Bank Group, Korea Herald, BBC, USA Today, and Business Insider WHY are FCV settings Q2 more vulnerable to case, resources for preparedness could easily fluctuate due to donors’ competing priorities. pandemics? Inaccessibility of some geographic locations due to insecurity not only delays initial detection, but limits the Fears and acute shocks like the 2014 Ebola outbreak, mobility of a country’s human resources for health or a conflict, can lead to public distrust of the (HRH) to respond to an outbreak. The 10th Ebola government. Weak institutions usually have a negative outbreak in DRC illustrates this challenge despite the effect on service delivery. Poor performance and cultural government’s improved response capacity and insensitivity in service delivery erodes trust, making it multistakeholder coordination. more likely that citizens avoid seeking care. In fact, attacks on the Ebola treatment centers in DRC obliged With their weak national systems, FCV countries tend to joint efforts of the government and development have lower technical capacity in disease partners to suspend necessary health service provision, surveillance, lacking cost-effective surveillance and caused panic, which led patients to flee treatment strategies and functional laboratories. Furthermore, centers. community-based surveillance systems are either non- existent or non-functional in these countries. Weak health systems struggle to maintain routine care during an outbreak, which severely strains their Countries with poor technical capacity and weak already limited health services, financial resources, surveillance systems have limited capacity in real- health workforce, and supply and procurement systems. time data collection, analysis, transmission, and Given more pressing health needs, such as high utilization for evidence-based planning and operations. maternal, neonatal and child mortality and morbidity, A big challenge remains in transitioning autonomy and competing priorities for budget allocation to other and sustainable financing from humanitarian sectors such as defense, economic development, trade responses to building or reinforcing national systems in and industry, and agriculture, FCV countries tend to the cycle of a disease outbreak. As disease outbreaks have lower investments in pandemic preparedness. are protracted, it would be more effective to integrate Moreover, pandemic preparedness would be more emergency responses into medium-term health systems effective when integrated into the existing health strengthening (HSS) efforts with a development lens. programs or projects. FCV countries likely have more vulnerable and mobile Given the fragility in governance, FCV countries, populations whose access to and utilization of health especially countries in active conflict, have huge services are limited or restricted. They are less challenges in mobilizing domestic resources for protected from, and are more susceptible to infectious health. They rely more on external funding, in which diseases, which do not respect national borders. 2 Q3 WHAT interventions could be considered? BOX 1 International Guidelines and Tools • IHR (2005) Monitoring and Evaluation Framework: Joint External Evaluation Tool aims to assess country capacity The Joint External Evaluation (JEE) for the to prevent, detect, and rapidly respond to public health International Health Regulations (IHR) Monitoring threats. and Evaluation Framework and the Evaluation of the Performance of Veterinary Services (PVS) are two • OIE Tool for the Evaluation of Performance of Veterinary Services is designed to measure a country’s performance fundamental tools that systematically assess a in veterinary services on 46 critical competencies in 4 country’s capacities across core domains. The results components (Human, Physical, and Financial Resources; of the JEE (framework below) and/or PVS serve as Technical Authority and Capability; Interaction with the starting point of identifying what needs to be Interested Parties; Access to Markets). financed in order to improve preparedness, with priorities in response to respective situations. • Global Health Security Agenda (GHSA) is a global partnership to help build countries’ capacity to create a Developing a national action plan for health security world safe and secure from infectious disease threats and (NAPHS), or a similar multisectoral action plan, elevate global health security as a national and global complemented by the Health Security Financing priority. Assessment tool (HSFAT), helps countries better • A national action plan for health security (NAPHS) is a plan prepare for pandemics. A plan could include which WHO guides its Member States to develop, following surveillance systems strengthening, building of JEE or other similar assessments. laboratory systems and networks, HRH • European Centre for Disease Prevention and Control enhancement, and establishment of an effective (ECDC)’s Guide to Revision of National Pandemic mechanism of risk communication. It would be useful Influenza Preparedness Plans - Lessons learned from the to identify areas which can be integrated into 2009 A (H1N1) Pandemic health systems strengthening (HSS) or UHC • Whole-of-Society Pandemic Readiness is a WHO service delivery and capacity building programs. guideline for pandemic preparedness and response beyond the health sector. JEE Framework with 19 technical areas (48 indicators) BOX 2 Investing in Other IHR-Related One Health Prevent Detect Respond Hazards and PoE • One Health is a concerted approach to address shared National risks to humans, animals and National Legistration, Preparedness the environment. Laboratory Policy and Point of Entry • Its application can also System Financing (PoE) reinforce other health Emergency objectives, such as RMNCH, IHR Response food and nutrition security, Coordination, Operations pollution management and Communication Real Time sanitation. and Advocacy Surveillance • Over 60% of infectious Linking Public Health and diseases in humans are of Antimicrobial Chemical Resistance (AMR) Security animal origin. Events Authorities Examples of countries with One Zoonotic Disease Health Platform; Reporting • Ethiopia • Cameroon Medical • Uganda • Sierra Leone Food Safety Countermeasures • Liberia • Bangladesh and Personnel Deployment Biosafety and Radiation The six technical areas where Biosecurity Workforce Emergencies the WBG is supporting the Development Risk governments through dialogue Immunization Communication and projects with its convening power. 3 Q4 WHAT has been done at the World Bank? What are the challenges & lessons learned? 15 World Bank lending projects with a Pandemic Preparedness and Response component in FCV settings. They are either regional or country specific, and independent from or integrated into HSS or UHC projects. (Appendix) 9 World Bank reports and papers on Pandemic Preparedness and Response since 2014 • Fact Sheet: The World Bank Support to the 10th Ebola Outbreak in the Democratic Republic of Congo (2019) • One Health Operational Framework for Strengthening Human, Animal and Environmental Public Health Systems at their Interface (2018) • Strengthening Post-Ebola Health Systems: From Response to Resilience in Guinea, Liberia, and Sierra Leone (2018) • From panic and neglect to investing in health security: financing pandemic preparedness at a national level (2017) • Drug-resistant infections: a threat to our economic future (Vol. 2): final report (2017) • 2014-2015 West Africa Ebola Crisis: Impact Update (2016) • The economic impact of Ebola on Sub-Saharan Africa: Updated estimates for 2015 (2015) • The economic impact of the 2014 Ebola epidemic: Short and medium term estimates for Guinea, Liberia , and Sierra Leone (2014) • Global program for Avian Influenza control and human pandemic preparedness and response: Project accomplishments (2014) BOX 3 Voices from the Field Common Challenges Emerged from Task Team Leader (TTL) Interviews Key Lessons Learned  Sustainable financing in preparedness and • Pandemic preparedness and response response is hard to attain in transition from acute planning should be integrated into wider emergencies to recovery or post-crisis phases. national systems strengthening efforts.  Given relatively lower investment in preparedness • The government and development partners and response vis-à-vis competing priorities like must consolidate their efforts for RMNCH, it remains a big challenge to strengthening preparedness and response operationalize a pandemic preparedness and capacities as well as mobilizing domestic and response plan with government ownership and external resources for prevention, detection and sustainability. Multistakeholder coordination is control at the early stage. critical to optimize resources. • Regionally coordinated approaches for the  Fragmented Community Health Workers control of selected priority diseases, (CHWs) programs by disease, which are often demonstrated efficiency in disease surveillance driven by donors’ priorities, accelerate insufficiency and response i.e. The Great Lakes HIV/AIDS, and unsustainability, thus leading to unmet needs East Africa Public Health Laboratory within the population. Networking (EAPHLN) Project for TB control, polio, meningitis, cholera and yellow fever.  Given fragility in governance and lack of performance monitoring systems at all levels, it is • Pooled procurement and management of critical to establish an effective, sustainable and other commodities or services for preparedness socio-culturally sensitive incentive mechanism for and response could result in financial savings health workers. due to economies of scale i.e. bed nets and TB treatments.  It is hard to monitor readiness on the ground. 4 TABLE 1 The World Bank’s Mechanisms for Pandemic Preparedness and Response (CERC and PEF) Catastrophe Deferred Drawdown Contingent Emergency Pandemic Emergency Option (CAT-DDO) Response Component Financing Facility (PEF) NB: Least likely applicable to (CERC) FCV situations Eligible IDA and IBRD Investment NOT used to finance IDA and IBRD Development Policy financing Project Financing (IPF) and preparedness but to finance Financing (DPF) for countries with Recipient-executed IPF surge response to IDA adequate Macroeconomic Policy financed by trust funds. countries, multilateral agencies, Framework and satisfactory and civil society organizations Disaster Risk Management (DRM) (CSOs). Program. Purposes CERC provides immediately PEF provides surge financing to CAT-DDO provides immediately available liquidity in the event of help prevent a high-severity available liquidity following a natural an eligible crisis or emergency. infectious disease outbreak from disaster and/or health-related becoming a pandemic. events. PEF Insurance Window – funds provided from the reinsurance market combined with the proceeds of catastrophe bonds PEF Cash Window – funds provided from a traditional donor-funded trust fund Coverage All-hazards, pre-determined PEF Insurance Window – Flu, All-hazards, pre-determined triggers for country/ project Coronavirus (i.e. SARS, MERS), triggers linked to a catastrophe in specific. Filovirus (i.e. Ebola, Marburg), country/ project specific context. Lassa Fever virus, Rift Valley fever virus, and Crimean Congo Hemorrhagic Fever virus PEF Cash Window – above plus other diseases with pandemic potentials. Activation Declaration of a state of When meeting the activation Declaration of a state of emergency or equivalent criteria, monitored by a third- emergency or equivalent “flexible” “flexible” triggered as agreed party observer. triggered as agreed between the between the WBG and WBG and national/sub-national A Recipient needs to submit the national/sub-national authority. authority. “request-for-funds” application, CERC can be activated without requiring a response plan and needing to first restructure outbreak risk assessment, the Original Project, thus, conducted and endorsed by facilitating rapid implementation WHO. with reallocation of uncommitted funds from an IPF. Time for < 2 weeks < 1 week < 1 week disbursement (<2 days in the case of DRC) Examples Lassa Fever outbreak in Nigeria 1st case applied for PEF in the Has not been activated for an (2018); CERC activated $2.5 9th Ebola outbreak in DRC outbreak emergency response. million. Ebola outbreak in DRC (2018); CERC allowed the country to reallocate up to $50 million for response. Limitations Reallocation of funds may Due to the requirement of a impact negatively the progress satisfactory macroeconomic policy towards the Project’s framework, CAT-DDO is unlikely to development objectives. be applicable for FCV situations. 5 The World Bank’s instruments in the cycle of a disease outbreak PEF CERC (activation) 1-3 months 3-9 months over 9 months Financial Supplemental Financing (AF, new IPF/DPF, CAT-DDO) Relief Stabilization System Strengthening Time Response Preparednes Source: Presentation on CERC at the WB Operational Clinic (prepared by WBG/GFDRR) BOX 4 Implications of Pandemics on the Private Sector Beyond the Health Sector • In addition to the already devastated direct impacts, pandemics often trigger fear and aversion behavior, which leads to changes in consumer consumption behavior, market share loss, job loss (or the loss of employees), and increase in commodity prices. • Little is known about the impact of pandemics on the informal sector. • The private sector could greatly contribute to pandemic responses with their financial and leveraging power for resource mobilization, early detection with its embeddedness in their communities, and preparedness with financing, goods, services, supply-chain management and R&D. (World Economic Forum 2015 report) Q5 HOW should we monitor and evaluate Pandemic Preparedness? The JEE and PVS are the first steps for countries to assess preparedness and response capacities. Each country needs to prioritize areas of focus, based on results of JEE and PVS assessments. One way to utilize the JEE tools is to have a self-assessment every two years on prioritized areas and to conduct a JEE every five years. However, ensuring sustained commitment to financing preparedness remains difficult due to competing politically sound priorities in fragile systems. WHO and the World Bank hosted the first meeting of the Global Preparedness Monitoring Board on September 10, 2018, which aims to monitor emergency preparedness across national governments, UN agencies, civil society and the private sector, and to advocate for the highest levels of health crisis preparedness. The FCV Health Knowledge Notes Series highlight operational tips to resolve health issues in FCV situations. These Notes are supported by the Middle East and North Africa Multi Donor Trust Fund and The State and Peacebuilding Fund (SPF). The SPF is a global fund to finance critical development operations and analysis in situations of fragility, conflict, and violence. The SPF is kindly supported by: Australia, Denmark, Germany, the Netherlands, Norway, Sweden, Switzerland, the United Kingdom, as well as IBRD. Author: Kazumi Inden, Health Specialist, Health, Nutrition and Population Global Practice, The World Bank Group For more information on other HNP topics, go to www.worldbank.org/health 6 Appendix: Health, Nutrition and Population Global Practice Lending Projects in FCV settings with a component on pandemic preparedness and response (except CERC) Challenges Project Size Year of TTL/Key Contact Pandemic Preparedness and Response Country Project and Lessons (million $) Approval Person Interventions Learned West Africa (P154807) Regional 114.06 2016 John Paul Clark, A regional IDA fund to strengthen national and ISR Report (Sierra Leone, Disease Surveillance Francois G. Le regional cross-sectoral capacity for Senegal, Guinea) Systems Enhancement Gall, Ibrahim collaborative disease surveillance and (REDISSE) Magazi epidemic preparedness in West Africa. The project components include (1) surveillance and information systems, (2) strengthening of laboratory capacity, (3) preparedness and emergency response, (4) human resource management for effective disease surveillance and epidemic preparedness, and (5) institutional capacity building, project management, coordination and advocacy. (Project Appraisal Document (PAD)) West Africa (P159040) Regional 147.00 2017 John Paul Clark, REDISSE Phase II (PAD) ISR Report (Guinea-Bissau, Disease Surveillance Francois G. Le Gall Liberia, Nigeria, Systems Enhancement Togo) Phase II (REDISSE II) West Africa (P161163) Regional 120.00 2018 John Paul Clark, REDISSE Phase III (PAD) ISR Report (Benin, Mali, Disease Surveillance Francois G. Le Mauritania, Systems Enhancement Gall, Patricia Geli Niger) Phase III (REDISSE III) West Africa (P152980) Ebola 105.00 2014 Preeti Kudesia, Emergency response to the Ebola outbreak ISR Report (Liberia, Guinea, Emergency Response Ibrahim Magazi, in West Africa. (PAD, PAD Additional Sierra Leone) Project Shiyong Wang Financing (AF)) East Africa (P153665) AFCC2/RI-3A 50.00 2015 Miriam Support 32 facilities for strengthening their (Kenya, EA PH Laboratory Schneidman laboratories to enhance surveillance and Tanzania, Networking Project emergency preparedness efforts in East Uganda, African Community (EAC) member states. Burundi) (PAD AF) Burundi (P129551) Burundi Public 15.00 2012 Sheila Dutta Establish a network of efficient, high quality, Health Laboratory accessible public health laboratories for the Networking Project diagnosis and surveillance of TB and other communicable diseases. (PAD) Cote d'Ivoire (P147740) Health 77.00 2015 Emre Ozaltin Strengthen the Government’s institutional ISR Report Systems Strengthening & capacity and capabilities in emergency Ebola Preparedness response preparedness, with a specific focus Project on communicable diseases, in the areas of disease surveillance, case diagnosis and management, and logistics and coordination. (PAD) Democratic (P169753) AF III DRC 226.50 2014 Hadia Nazem Strengthen disease surveillance and ISR Report Republic of Health System Samaha response. Preparedness for the Ebola, Congo Strengthening for Better Yellow Fever, a Cholera epidemic. (PAD, Maternal and Child PAD AF, PAD AF III) Health Results Project (PDSS) Gambia (P159693) Maternal and 7.50 2017 Samuel Lantei Mills Health system strengthening for Ebola Child Nutrition and Health preparedness and control (PAD, PAD AF) Results Project Haiti (P163313) Improving 25.00 2017 Andrew Sunil Strengthen cholera control and strengthen Maternal and Child Rajkumar social services, in areas affected by Hurricane Health Through Matthew in particular. (PAD AF) Integrated Social Services Project Liberia (P162477) Liberia Health 15.00 2013 Preeti Kudesia Complementary to the Ebola Emergency ISR Report Systems Strengthening Response Project (P152359), support for recovery in post-Ebola, health systems strengthening and resilience building. (PAD Restructuring) Myanmar (P160208) Essential 100.00 2014 Hnin Hnin Pyne Health systems strengthening, including ISR Report Health Services Access scaling up infection control and health care Project waste management and improving pandemic preparedness. (PAD Restructuring) Republic of (P143849) Health Sector 120.00 2013 Gyorgy Bela Integrated diseases surveillance and ISR Report Congo Project Fritsche, Hadia response. (PAD Restructuring) Nazem Samaha Sierra Leone (P153064) Health 15.50 2016 Shiyong Wang Complementary to the Ebola Emergency ISR Report (NB: Sierra Leone Service Delivery and Response Project (P152359), support for is not listed in the System Support Project recovery in post-Ebola, health systems harmonized list of (HSDSSP) strengthening and resilience building. FCV countries in Introduction of PBF for health facilities and FY19 but had been CHWs, continuous support for multi- listed in the disciplinary clinical teams in transition for harmonized list of HRH. (PAD Restructuring) FCV countries until FY18.) Yemen (P164466) Yemen 200.00 2017 Moustafa Emergency response to Yemen crisis. AF2 is ISR Report Emergency Health and Mohamed El Sayed for an emergency response to the Cholera Nutrition Project Second Mohamed Abdalla, outbreak of unprecedented scale in Yemen. Additional Financing Yogita Mumssen (PAD, PAD AF1, PAD AF2)