How to Assess a Country’s Preparedness to Face a Public Health Emergency? A Scoping Review

1. Introduction

A health crisis can impact a country's morbidity and mortality and can even spread quickly to other countries. This situation requires every country to be prepared to deal with emergencies caused by health crises. Assessing a country's emergency preparedness involves technical aspects or resources and diverse social, cultural, and political dynamics. It is, therefore, challenging for a country to assess its preparedness because emergencies are often unpredictable (Khan et al., 2018). Various health system preparedness assessment concepts are used to measure the preparedness of health system actors, such as health facilities, to be prepared for infectious disease outbreaks and other health emergencies.(Nuzzo et al., 2019). Preparedness assessments illustrate progress, identify gaps, inform decision-makers, and indicate where investment in preparedness is needed. (Institute, 2018).

The International Health Regulations (IHR), revised in 2005 due to the global health crisis, are designed as a key health security instrument to prevent and address significant health threats internationally. Preparedness assessments serve several important purposes. They help demonstrate progress, identify gaps, inform decision-makers, and indicate areas where investment in preparedness is necessary.(Kluge et al., 2018). More than 100 countries have adopted the Joint External Evaluation (JEE) process, and WHO assessments are now used to measure global preparedness for infectious disease outbreaks and other public health emergencies. However, the JEE only assesses a few capacities and capabilities required for health system preparedness and response. Health systems play a direct role in supporting countries' ability to respond quickly and efficiently to infectious disease outbreaks, so it is important to consider health system preparedness for these events as countries assess their overall preparedness. A framework or tool that comprehensively identifies the health system capacities and capabilities required for effective outbreak preparedness and response is needed. (Nuzzo et al., 2019). The COVID-19 pandemic at the global level shows the importance of evaluating the Government's preparedness in responding to emergencies (Meyer et al., 2020). Until 3 years have passed globally, 676,609,955 people have been confirmed infected with COVID-19, and 6,881,955 people have died (University, 2023). The emergence of these pandemics highlights new threats related to public health. Emerging disease events like this have challenges to handle because the Government must meet the high demand for resources in the community. However, this fulfillment cannot be achieved in the short term because virus transmission is unpredictable, and the virus's situation cannot be known due to its effects and weaknesses (Hossain, Akter, Rashid, Khair, & Alam, 2022). A country's emergency response capacity requires improvement to control the threat effectively (Haider et al., 2020).

Various parameters are used to evaluate and assess a country's preparedness for health emergencies. Various instruments have been developed to evaluate national and subnational (regional/local) country-specific preparedness that may only apply to some countries, given the specific characteristics of a country's health and public health emergency response system (Haeberer et al., 2021). Using data from the article search, this checklist analyzes the parameters used to assess the Government's preparedness for health crisis emergencies.

2. Method

A team of pharmacists and public health officials conducted the scoping review. Four authors (ESS, DA, PJ, SS) were responsible for data extraction and analysis.

2.1. Search strategy

Article search strategy through online search on electronic databases conducted in February - March 2024. The databases used were Proquest, Pubmed, Sage, ScienceDirect, and Scopus. The stages carried out include (a) identifying research questions, (b) identifying relevant research in predetermined databases, (c) selecting studies that match the predetermined criteria, (d) extracting and charting data, and (e) summarising and reporting results. The search used specific and uniform keywords, as in Table 1. 

Table 1: Searches strings

2.2. Inclusion criteria

The article search results were processed and analyzed using the Endnote X9 application. The article search criteria used included: (1) all articles related to the assessment or evaluation of government preparedness for health emergencies; (2) original research full-text written in English; (3) all design studies; (4) articles published from 1 January 2018 to 31 December 2023.

2.3. Exclusion criteria

Exclusion criteria used were (1) articles that did not contain parameters or assessments of state preparedness in facing health emergencies; (2) articles in the form of review articles, study protocols, conference paper commentaries, series, letters to the editor, news, books, guidance or other types of articles not based on primary data collection; (3) publications in non-English journals; (4) abstract only.

The total number of articles obtained from 5 databases is 3,919. After screening using the PRISMA flow diagram, selected articles were reduced due to duplication, incompatibility of titles and abstracts with themes, and screening of full text needed an instrument or component of measuring preparedness, so 13 suitable articles were obtained. (Aceng et al., 2020; Bakiika et al., 2023; Coccia, 2022; Guyo et al., 2022; Huang & Yu, 2023; Neogi & Preetha, 2020; Oppenheim et al., 2019; Sajjad, Raza, & Shah, 2022; Talisuna et al., 2019; Kyeng Mercy Tetuh et al., 2023; Ul-Haq et al., 2019; Van Hoang, Tran, Vu, & Duong, 2021; Zhao et al., 2023). The results of the article screening can be seen in Figure 1.

Figure 1: PRISMA flow diagram showing screening and selection of published articles

3. Results

A comprehensive search was conducted on five sources: Proquest, Pubmed, Sage, ScienceDirect, and Scopus. The results of the articles obtained were 3,919 relevant articles according to the keywords that have been determined. After screening this scoping review, 13 articles met the predetermined inclusion and exclusion criteria. The data for each study was mapped using the following headings: first author, year of publication, title, country, research objectives, research design, tools/instruments, and research results. The results of the data extraction can be seen in Table 2.

Based on the screening results, all articles (n=13) discussed government preparedness in dealing with emergencies in infectious disease hazard situations. Most of the infectious disease hazards in this article are exposure to infectious diseases such as the Ebola virus, MERS, SARS, and COVID-19. Most articles discussing indicators of a region's preparedness in facing health emergencies were published in 2023 (n=4), and the rest were divided into 2019-2022. There has been an increase in research in these years because, at that time, the global situation had just faced the COVID-19 pandemic, so an evaluation was carried out on the preparedness and preparation of a country and government to deal with emerging diseases. This pandemic event is a starting point for governments globally to evaluate how prepared their countries are in the face of disasters. The study design in this research mainly uses a quantitative approach (n=9), and the rest uses a mixed methods approach. The search results showed that 11 instruments/assessments are used to assess preparedness for health emergencies. The characteristics and explanations of each article can be seen in Table 2.

Each instrument used has parameters that become a reference for assessing the preparedness of an area in the face of a disaster or emergency. The parameters used, although different instruments and limitations and strengths of each instrument, can be seen in Table 3.  In table 3 it describes the use of instruments from the reviewed articles, objectives, usage topics, scope, strength, limitation, and validity. A total of 12 articles used instruments, and one other article was analyzed without instruments. The instruments used can measure various regional, national, and global levels. Most of the instruments used in the above articles are Joint External Evaluation and WHO's toolkit for assessing health system capacity for crisis management. The indicators or parameters used in each instrument have a different number of domain items or indicators, which can be seen in Table 4.

There are 11 instruments used to assess the preparedness of an area for emergencies, especially health crises. Overall, there are no parameters that cover all instruments. Based on this data, factors commonly found as indicators in assessing the preparedness of an area in the face of a disaster can be extracted. The most common indicators include surveillance, financing, physical infrastructure preparedness, emergency response operations, coordination, and the health workforce. The different indicator domains for each instrument can be seen in Table 5.

Table 2: Characteristics of the included studies

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Table 3: Instruments that can be used to assess government preparedness for health crisis emergencies

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Table 4: Indicators used in each of the Health Crisis Emergency Preparedness Assessment Instrument

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Table 5: Differences in each indicator on each preparedness assessment instrument

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4. Discussion

Monitoring the risks and vulnerabilities of a region, whether a country or a city/district, needs to be done regularly. This monitoring is necessary to ensure that each region, government, and community is prepared for emergencies such as health crises. Monitoring in the face of emergencies is necessary to identify weaknesses and strengths of the health and disaster preparedness system. The assessment results are helpful to illustrate and become a reference for decision-making in formulating strategies to improve a region's response to emergencies in the future. The results of this literature search indicate that 11 assessments or measurement tools can be used to assess preparedness at both the country and regional levels for emergencies. This study summarizes the various instruments or assessments to evaluate preparedness and looks at what indicators or factors are the parameters of preparedness. This can determine what factors make up the majority of emergency preparedness assessments, especially in emerging disease situations.

The most common instruments or assessments in the literature search above are the JEE and WHO's toolkit for assessing health-system capacity management. The JEE covers 19 technical areas: national policy, coordination, risk communication, epidemiological surveillance, and emergency response (Kentikelenis & Seabrooke, 2021). The JEE assesses a country's ability to fulfill International Health Regulations (IHR) and preparedness for global threats. The assessment can be done by a country's self-assessment, which conducts a comprehensive evaluation of the country's Health system in its capacity for prevention, detection, and response to epidemics and pandemics, as well as an external assessment from a team that will conduct an in-depth evaluation and provide recommendations. (Nguyen et al., 2021).  WHO is Six Building Blocks, an important tool to assess and strengthen a country's health system. Although it has the same purpose, this system analyses the health system as a whole. It is divided into six main components: health service delivery preparedness, health workforce, health information system, essential medicines, health financing, and governance. The assessment is conducted in more depth for each block and evaluated based on specific indicators to see the strengths and weaknesses of the health system. (Organization, 2010). The difference between the two assessments can be seen if the JEE provides recommendations to provide a country's health preparedness capacity so that it can develop action plans against global threats, while the Six Building Blocks model is to develop health policies and improve the efficiency and effectiveness of health services because it assesses the whole health service. (Fall et al., 2023; Organization, 2023). Therefore, if a country evaluates with both, it can complement each other in preparing the country for a health crisis and strengthening the health system to increase global health security.

The most significant number of assessment parameters is found in the GHSI, which assesses preparedness and ability to deal with global health threats, including pandemics and epidemics. This indicator consists of 6 categories and 37 indicators developed to encourage the acceleration of improving national health security and international capabilities in addressing the most dangerous health risks, namely infectious disease outbreaks that can cause international epidemics and pandemics (Nuclear Threat Initiative, 2021). The results of the assessment using the GHSI index in 2019 in 195 countries show that no country is ready to face the threat of future epidemics and pandemics. Each country's national Health security needs to be stronger, and no country is fully prepared for an epidemic or pandemic. However, some studies show the GHSI has poor predictability and does not meet the needs of policymakers in society (Kaiser, Chen, & Gluckman, 2021).

The indicators or factors in each measurement become parameters that need to be prepared in each country in the face of emergencies. In general, the preparedness parameters most valued as factors that need to be prepared in an emergency are surveillance and financing preparedness. Instruments that include these two indicators as aspects of preparedness in dealing with emergencies are the assessment instruments using the Preparedness Index and Resilience Index, GHSI, JEE, EBS, and WHO EBV. In addition, parameters that often appear include physical infrastructure preparedness, emergency response operations, coordination, and the health workforce.

Surveillance is important in early detection, rapid response, and resource management. This aspect needs to be guaranteed to provide information related to emergencies and impacts, allowing a country to intervene more quickly before the disaster becomes more severe (Sukardi, Kataren, Rohana, Dachi, & Tarigan, 2022). Data obtained from the surveillance process helps in planning and decision-making, such as allocating resources more efficiently, designing health programs, and developing responsive policies. A robust surveillance system will enhance a country's ability to respond quickly and effectively to emerging health challenges. (Khatri et al., 2023). Then, the financing aspect plays an important role too because it is a source of preparing health resources (McMahon, Peters, Ivers, & Freeman, 2020). Financial resources are a necessary indicator in the event of a disaster because they can fulfill the pandemic preparedness needs. The government should have a long-term vision of financial resources, as the ongoing impact of the pandemic affects the country's budget collection sources. (Boyd, Wilson, & Nelson, 2020).  Governance is only effective if there is money to pay for health workers, medicines, and hospitals; all factors can help access them (Ajisegiri, Chughtai, & MacIntyre, 2018).

Health infrastructure also plays an important role in preparing to reduce the impact of the health crisis. Any development in an area must also consider the potential risk of future disasters. Careful planning can make facilities available and ready to deal with emergencies more effectively (Hassan et al., 2023; Radford et al., 2024). Emergency response operations also play an important role in a country's preparedness for a health crisis. This is because preparing for the next epidemic or pandemic is important, as well as knowing the risk factors so that public health and medical emergency plans can be coordinated and activated effectively and timely. In an emergency such as this, it is seen that Rapid Response, Detection, and Reporting have the most impact (Chang & McAleer, 2020; Hassan et al., 2023). One of its greatest strengths in health service delivery is immediate notification following early detection and confirmation of a case. Improving health system resilience is the most fundamental approach to infectious disease prevention and control. In Indonesia, the government delayed the public health emergency response to avoid a sizeable economic impact, and as a result, had the highest number of confirmed cases in March 2020 in Southeast Asia. This exacerbated a significant imbalance in access to health services. (Olivia, Gibson, & Nasrudin, 2020). In managing a country's emergency preparedness, effective cross-sector coordination is essential. The synergy of various agencies can respond quickly to emergencies. The coordination that is formed can equalize perceptions and strategies in dealing with disasters, thereby reducing the risk of overlapping responsibilities (Arslan, Golgeci, Khan, Al-Tabbaa, & Hurmelinna-Laukkanen, 2021). The role of the government and laws and regulations related to outbreak control is very important, including cross-sector cooperation, and serves to sanction violations in pandemic control. (Van Hoang et al., 2021). Good coordination across sectors can ensure that the country is ready to face future health challenges.

Another factor widely valued as a parameter of preparedness is related to the preparedness of health workers. Health workers are a fundamental part of the health system; they perform duties that include carrying out medical research to improve disease prevention, diagnosis and treatment, clinical consultation, and provision of care to safeguard each patient. In practice, health workers are closely related to communication because they act as allies in dealing with the pandemic, especially in raising awareness among the public and fighting the stigma associated with the disease. (Aceng et al., 2020). Health workers face a more significant and stressful workload than usual during an epidemic, so they must be more resilient and adapt quickly to the changing situation (Chen et al, 2020). When faced with a public health crisis, health workers are often the first to respond. Adequate mobilization and coordination of health workers and medical supplies can significantly reduce mortality (Hanefeld et al, 2018).

Evaluating pandemic preparedness and control globally is important because each country has very different policies and practices depending on country-specific conditions. Adapting, validating, and routinely improving the validity of tools in health systems is an important process in disease control and prevention (Tran et al., 2022). Few preparedness assessment tools are available electronically and are user-friendly in facilitating participant and stakeholder data collection, analysis, dissemination, and discussion of results. This should be one of the drivers for developers to produce assessment tools in a more user-friendly manner (Haeberer et al., 2021). The findings in this study also illustrate a need to improve the current tools, such as proposing new fields to develop new tools with parameters customized to country-specific conditions, especially for infectious disease control. Further research is needed to develop specific domains for each country's priorities, given that most current tools may be broad. For example, some important variables for epidemic preparedness, such as community variables (e.g., population density, community interaction, or coverage of different protective measures) and individual factors (e.g., knowledge-attitude-practice, social networks, or trust in government), should be included and measured (Kundu et al., 2021).

5. Conclusion

Regularly monitoring the preparedness of a country and its respective regions is vital to ensure a swift and effective response to health crisis emergencies. This comprehensive assessment not only sheds light on the existing strengths and weaknesses of the health system but also identifies specific strategies that need to be implemented for improvement. Various measurement tools, such as the Joint External Evaluation (JEE) and the World Health Organization's (WHO) Toolkit, can be used to conduct a thorough evaluation. These tools are critical in gauging a country's capacity to prevent and respond to epidemic and pandemic situations. Several key factors are assessed as parameters of preparedness for health crises, including the preparedness of surveillance systems to detect and monitor outbreaks, the availability of sufficient financing to support health initiatives, the robustness of healthcare infrastructure, the effectiveness of cross-sector coordination, the adequacy of the health workforce, and the overall emergency response preparedness capabilities. A preparedness evaluation enhances a nation's ability to tackle future health challenges. Such evaluations bolster individual countries' health systems and strengthen the global health infrastructure, ensuring a more resilient response to upcoming health threats.

Author Contributions: Conceptualization: ESS, DA. PJ, S. Data curation: ESS, DA. Methodology: ESS, DA, PJ, S. Supervision of the study: DA. PJ, S. Writing-original draft: ES, DA. Writing-review and editing: ES, DA, PJ, S. All the authors contributed to the article and approved the submitted version.

Funding: This works supported by the Indonesian Endowment Funds for Education (LPDP) for Financial Support for education and research dissertations.

Conflicts of Interest: The authors have no conflicts of interest associated with the material presented in this paper.

Ethics Statement: This paper synthesizes secondary evidence from other published studies; thus, ethics approval was not required. No primary datasets were generated or analyzed for this study. Therefore, consent to participate is not required.

Declaration of Generative AI and AI-assisted Technologies: This study has not used any generative AI tools or technologies in the preparation of this manuscript.