World Health Organization Joint External Evaluations in the Eastern Mediterranean Region,2016-17

Abstract

By 2014, only 33% of countries had self-reported compliance with the International Health Regulations (2005), including 8 countries from the Eastern Mediterranean Region (EMR). During the Ebola epidemic, the discovery of a gap between objective assessment and self-reports for certain IHR capacities prompted the World Health Organization (WHO) to review and update the IHR monitoring and evaluation framework to include a voluntary objective review process, called Joint External Evaluation (JEE), that did not exist before. The regional committee for the EMR approved the JEE and encouraged its 21 member states to volunteer for reviews. Standardized processes and procedures were developed for conducting JEEs. Of the 52 JEEs completed to date globally, 14 (27%) are from the EMR. Three (21%) of 14 member states completing the JEE in the EMR have also worked on a post-JEE national action plan for health security (NAPHS). A survey conducted about the JEE experience from focal points in EMR member states underlined the strengths of the JEE process: its multisectoral and open discussion approach; standardization of the JEE process; WHO's critical role in supporting JEE preparation and conduct; and the need for guidance development for a costed NAPHS. The success of JEEs depends not only on proper preparations and completion of the JEE but also on the development of a country-led, owned, and costed NAPHS and its implementation, including financial commitments along with donor and partners' engagement and coordination.

A survey conducted about the Joint External Evaluation (JEE) experience from focal points in Eastern Mediterranean Region member states underlined the strengths of the JEE process: its multisectoral and open discussion approach; standardization of the JEE process; WHO's critical role in supporting JEE preparation and conduct; and the need for guidance development for a costed national action plan for health security.

The renewed attention on emerging infectious diseases of international importance in the 1970s and 1980s (notably HIV/AIDS in the latter decade) led to political pressure in May 1995 for the World Health Assembly to adopt resolution WHA48.7, requesting the director-general to undertake a revision of the 1969 International Health Regulations (IHR).¹ This resolution reflected the conclusion of WHO and its member states that the IHR provided an inadequate framework through which to address the growing threat of public health events.²

A series of expert consultations and working groups were conducted to build and secure consensus on a new direction, and several World Health Assembly resolutions were adopted throughout the revision process over a period of 10 years (1995-2005).^3-5 However, in 2002-03, the emergence and rapid international spread of severe acute respiratory syndrome (SARS) triggered an urgent need for WHO to accelerate the revision of the IHR. As a result, an intergovernment working group was established for all member states to review and recommend a draft revision of the IHR for consideration by the health assembly under Article 21 of the WHO constitution.⁶ In its final plenary meeting on May 14, 2005, the working group agreed on the draft revised IHR, which was submitted and adopted in May 2005 by the 58th World Health Assembly.^7,8

The revised IHR—called IHR (2005)—greatly expands the range of events to which the regulations apply and introduces a radical paradigm shift: from a limited focus on controlling diseases at borders to quickly tackling any outbreak at its source. The purpose of IHR (2005) is “to prevent, to protect against, control, and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.”⁹ The scope and thus the purpose of the IHR (2005) are determined predominantly by public health considerations and not trade concerns, which is different from the old IHR.

Monitoring Framework for IHR (2005) Capacities

In accordance with Article 54 of the IHR (2005), member states and the director-general should report to the health assembly annually on the implementation of the regulations. As a result, WHO developed a monitoring framework for the IHR (2005) capacities.¹⁰ The monitoring framework includes a checklist, indicators, and self-assessment questionnaire. It involves assessing the implementation of 8 core capacities and the development of capacities at points of entry and for IHR-related hazards, notably biological (ie, infectious, zoonotic, food safety, or other), chemical, radiological, and nuclear hazards. The purpose of the monitoring tool was to help individual countries monitor progress toward meeting the core capacity requirements and to address any identified gaps.¹¹

All 21 member states in the Eastern Mediterranean Region (EMR) annually report on their progress in IHR implementation using the self-assessment questionnaire. Results generated from these questionnaires indicated good progress (defined as a score of 70% or better) in the implementation of IHR capacities in the EMR, specifically in surveillance (18 of 21 member states), laboratory (12/21), risk communication (14/21), legislation (17/21), coordination (15/21), and food safety (16/21). However, capacities for preparedness (9/21), human resources (9/21), points of entry (10/21), and for handling chemical (13/21) and radionuclear events (10/21) remained low (Table 1).¹²

Table 1.

International Health Regulations (2005): Level of Core Capacity Implementation (%) in the Eastern Mediterranean Region, 2012-2014

	Implementation Score (%)
IHR Capacity	2012	2013	2014
Chemical	47	53	51
Radionuclear	58	60	60
Points of entry	52	55	63
Preparedness	59	62	63
Human resources	63	69	67
Risk communications	62	67	71
Laboratory	76	76	72
Food safety	69	75	74
Coordination	72	77	80
Legislation	74	75	81
Response	74	78	82
Surveillance	81	84	84
Zoonosis	85	86	84

Source: Global health observatory data repository: IHR core capacities implementation status, WHO Eastern Mediterranean Region. Geneva: World Health Organization; 2014. http://www.who.int/gho/ihr/en/.

Three major IHR-related events took place at the regional and global levels in 2014, specifically related to the Ebola outbreak in West Africa, which have contributed to the change in the approach to monitoring the implementation of IHR capacities. First, the regional office carried out missions to all countries of the EMR to assess their national capacities for preparedness and responses to Ebola as requested by the WHO regional committee for the Eastern Mediterranean (EMRC resolution EM/RC/61/R.2), as did other WHO regional offices.¹³ Second, the review committee convened in November 2014 to advise the director-general on requests from states parties on second extensions (2014 to 2016) for establishing the core capacities to detect and respond to events as specified by Annex 1 of the IHR. The review committee also advised the director-general on how to better strengthen and assess IHR core capacities in the short- and long-term. Third, the Ebola Interim Assessment panel was established in early March 2015 to assess all aspects of WHO's response in the Ebola outbreak.¹⁴

Shift in Monitoring of IHR (2005) Capacities

The Ebola assessment missions revealed information inconsistent with what was reported by countries through the IHR self-assessment tool between 2010 and 2014.¹⁵ The IHR review committee, in its report of May 2015, recommended that the secretariat “develop through regional consultative mechanisms options to move from exclusive self-evaluation to approaches that combine self-evaluation, peer review and voluntary external evaluations involving a combination of domestic and independent experts.”¹⁶ Furthermore, the Ebola Interim Assessment Panel, in its final report of May 2015, stated, “WHO will need reliable information about the current situation of public health capacities in each country. This requires some form of peer review or other external validation.”¹⁷

WHO subsequently revised the IHR monitoring framework to reflect the recommendations of the review committee and the Ebola Interim Assessment Panel. A concept note outlining this revised approach was discussed by the WHO regional committees in 2015.¹⁸ Independent evaluation of IHR capacities has been proposed as one component of the revised approach to monitoring of IHR (2005) capacities.

The need for an objective independent assessment of IHR (2005) capacities has been taken forward by the office for the EMR. As a result, a resolution was submitted to the Sixty Second Eastern Mediterranean Regional Committee (EMRC) to encourage member states to conduct objective assessment of IHR (2005) capacities.¹⁹

Subsequently, the EMRC Resolution (EM/RC62/R.3) was adopted, supporting the above and also requesting the establishment of (1) an independent IHR Regional Assessment Commission (IHR-RAC) to advise member states in the EMR on issues relating to implementation of the national core capacities required under the regulations, and (2) a regional taskforce to harmonize the existing tools for the assessment of implementation of the IHR, including the Global Health Security Agenda (GHSA) assessment tool.²⁰ The GHSA is an initiative that supports the implementation of the IHR (2005), the World Organization for Animal Health's (OIE) Performance of Veterinary Services Pathway (PVS), and other relevant global health security frameworks in promoting global health security. It was launched in February 2014 at the US Department of Health and Human Services with representatives of 26 nations, the WHO, the Food and Agricultural Organization of the United Nations (FAO), and the OIE to prevent, detect, and effectively respond to infectious disease threats, whether naturally occurring or caused by accidental or intentional releases of dangerous pathogens.²¹

Joint External Evaluation Tool

A technical consultation was organized by WHO in Lyon, France, in October 2015. The consultation concluded with consensus on development of a common process, later named the Joint External Evaluation (JEE), and outlining a single global evaluation tool based on extant evaluation and assessment tools. The “joint” in this case was intended to refer to an evaluation by a multidisciplinary external team of experts and multisectoral national experts.

The WHO headquarters along with the regional office for the Eastern Mediterranean (EMRO) led the global effort to conclude the discussion. As a result, the JEE tool for assessing IHR (2005) capacities was finalized as an outcome of a second technical consultative meeting organized in January 2016, as were the features of the JEE process.^22,23 The WHO Global Policy Group (GPG), which includes the participation of the WHO director-general, the WHO executive director for emergencies, and the 6 elected regional directors, in its meeting of February 2016 subsequently endorsed the tool to be used as the single standard WHO instrument for externally assessing IHR (2005) capacities of member states.

The revised framework—the IHR Monitoring and Evaluation Framework (IHR M&EF) with 4 components of annual reporting, JEE, after-action review, and simulation exercise—was noted by the 69th World Health Assembly.²⁴ Annual reporting (self-assessment) is the only mandatory component under the IHR M&EF, in accordance with Article 54 of the IHR. The 3 other components are voluntary; however, states parties are encouraged to conduct them to identify gaps in national public health capacities and to improve them so as to rapidly and efficiently respond to threats to health security.

The IHR M&EF suggests that all countries organize at least 1 JEE every 3 to 5 years. The JEE is a voluntary, multisectoral process, using a standardized tool (ie, assessment instrument) and process to evaluate country capacity, as required by the IHR (2005) to prevent, detect, and rapidly respond to public health risks, whether natural or due to deliberate or accidental events.

The JEE tool consists of 19 technical areas (Table 2). Each technical area is measured by incremental 5-step indicators containing definitive cut-off criteria. The score for each indicator ranges from 1 to 5 as follows: 1, no capacity; 2, limited capacity; 3, developed capacity; 4, demonstrated capacity; and 5, sustainable capacity. Technical areas have 1 to 5 subindicators each. Only integer scores are allowed.

Table 2.

The IHR Technical Areas by Function as Described in the Joint External Evaluation Tool

Function	Technical Areas
Prevent	National legislation, policy and financing, IHR coordination and communication, antimicrobial resistance, zoonotic disease, food safety, biosafety and biosecurity, and immunization
Detect	National laboratory system, real-time surveillance, reporting, and workforce development
Respond	Preparedness, emergency response operations, linking public health and security authorities, medical countermeasures and personnel deployment, and risk communication
IHR-related hazards and points of entry	Points of entry, chemical events, and radiation emergencies

Source: World Health Organization. IHR (2005) Monitoring and Evaluation Framework, Joint External Evaluation Tool. WHO, Geneva, 2016. http://apps.who.int/iris/bitstream/10665/204368/1/9789241510172_eng.pdf?ua=1.

Material and Methods

Establishing Standardized JEE Process

To ensure consistency of the JEE process, standardized processes and procedures were developed for conducting JEEs in EMRO using the JEE tool. The standardized process included the following steps:

1. A 2-day preparatory meeting was conducted in each country 2 to 3 weeks before the JEE, with the aim of orienting nationals on the JEE process and tool, supporting nationals in completing the JEE tool for self-evaluation, and identifying background documents for the review of the JEE team;^* EMRO developed standard presentation and guidance documents for the preparatory meeting for EMR member states.

2. The completed self-evaluation along with background documentation on the 19 technical areas was shared with the external JEE expert team 1 to 2 weeks before the in-country mission.

3. A 1-day orientation was conducted for the external team a day before the start of the mission on the JEE tool, how to administer it, and how to facilitate the discussion with nationals in order to reach consensus on scoring the technical areas and identifying priority actions.

4. A team of an average of 14 subject matter technical area experts representing international organizations, peer countries, and technical institutions and universities participated in each mission to evaluate 1 to 2 technical areas each.

5. A standard agenda was established of 5-day meetings with all national stakeholders relevant to the implementation of IHR (2005), including field visits to hospitals, primary healthcare centers, public health laboratories, veterinary laboratories, poison centers, emergency operating centers, airports, ports, and ground crossings. These were conducted during the 5-day mission to validate the information collected through the self-evaluation tool and background documents (the venues for field visits varied by country depending on feasibility and time).

6. A debriefing meeting with high-level and technical officials was held at the end of each mission to present a summary of findings, final scores, and 3 to 5 priority actions that the country should undertake to advance in IHR (2005) implementation.

7. A report was developed after each mission that included the aforementioned scores and priority actions and also described the capability of countries in each technical area, along with strengths and weaknesses of each indicator. The reports were shared with nationals for fact checking and final approval within 2 weeks of completion of each JEE mission. These reports are publicly available on the WHO webpage.²⁵

The EMR member states followed these processes and procedures.

Focal Point Survey on JEE Experience

A brief survey was conducted with focal points in the 14 EMR member states that volunteered and completed JEEs. The national IHR focal points, as well as the focal points who were responsible for coordination of conducting JEEs for 19 technical areas and were designated by the member state itself, completed the survey in person or submitted their responses via email at the end of their respective JEEs to provide feedback on their experience. Confidentiality was ensured by removing responders' names and country from the survey responses and interview notes prior to conducting the analysis. The survey was conducted on a not-for-attribution basis in order to promote honest, transparent responses. The questionnaire asked participants to describe the value of the JEE process and their interest in repeating the process in the future; it also provided them an opportunity to discuss the absence of value added or limitations of the process in subsequent questions (Table 3).

Table 3.

Questionnaire Used to Survey the Focal Points of the Joint External Evaluation in Each of the 14 Member States

Questions	Answers
What is the added value of the JEE?	Please explain.
Will your country be interested in conducting the JEE in 4 years?	Yes □ No □
What are the limitations of the JEE?	Please explain.
How can the JEE be improved?	Please explain.

Developing Post-JEE National Action Plan

Guidance was provided to member states completing JEEs to develop their country-led, country-driven, and country-owned national plans of action for health security and to build their capacities to address the identified gaps.

Results

Facilitating JEEs for the Region

Implementation of the JEE process has been a priority in the EMR. One of the main reasons for its success is the EMRO Resolution (EM/RC62/R.3) that established the foundation for member states in the EMR to request and host the JEE. Furthermore, the Sixty Third EMRC adopted a Resolution (EM/RC63/R.1) and requested JEE by member states that had not already undergone it, including development of plans of action based on the outcomes of the JEE.²⁶ As a result of adoption of the resolution, of the 52 countries across the world completing JEEs by July 2017, 14 (27%) are in the EMR: Afghanistan, Bahrain, Jordan, Lebanon, Morocco, Pakistan, Qatar, Somalia, Sudan, Tunisia, Kingdom of Saudi Arabia, Oman, United Arab Emirates, and Kuwait. An active effort is ongoing to support completion of JEEs in the remaining 7 EMR countries as soon as feasible. At least 4 of these countries (Iraq, Libya, Syria, and Yemen) are fragile states, currently facing ongoing conflict and/or humanitarian crises. These countries will require substantial WHO EMRO support to plan and complete JEEs, ensuring integrity of the standardized process.

Experience and Feedback on JEEs

All 14 focal points surveyed from countries completing JEEs confirmed the added value of the multisectoral approach of the JEE in bringing sectors together to identify the country capability in each technical area and the transparency and open discussion policy featured in these JEEs. No major limitations were identified by the 14 focal points. However, 10 (71%) focal points highlighted that more time was needed for preparations to ensure the involvement of all concerned sectors and to collect existing national documents as background materials to help with validation of JEE criteria and scoring.

All focal points surveyed confirmed adhering to the standardized JEE process and procedure. However, all highlighted the need for WHO to continue conducting preparatory meetings to orient nationals on the JEE process and tools. Also, 8 (57%) focal points raised the importance of the involvement of nongovernment sectors, partners, and donors in the JEE to subsequently facilitate the development, financing, and implementation of national action plans for health security. And 2 (14%) focal points emphasized the need to link the current short-term emergency response activities with long-term capacity-building activities based on the JEE outcomes.

Additionally, financing and technical support for implementation were considered a critical need to negate any negative political perceptions related to JEEs. All 14 focal points emphasized the continued need for the leadership role of WHO in guiding member states in developing a process for formulating national action plans for health security as well as a costing tool, and they stated that their member states are willing to conduct a second round of JEE after 4 years (Table 4).

Table 4.

Summary of Outcomes of the Surveyed Focal Points for Experience on the Joint External Evaluation of the 14 Member States

Questions	Answers (number of countries)
What is the added value of the JEE?	• Brings all sectors together with high-level commitment (14) • Discussed technical areas openly and transparently (14) • A way to identify gaps and improve national capacities (14) • A way to implement roadmap for GHSA (2)
Will your country be interested in conducting the JEE in 4 years?	• Yes (14) • No (0)
What are the limitations of the JEE?	• No major limitations (14) • Insufficient time for preparation (10) • Limited field visits to validate collected information (2) • Instability of security situation and so JEE conducted in a neighboring country (1)
How can the JEE be improved?	JEE Process • Self-assessment part of the JEE to get familiar with the process (14) • Preparatory meeting to orient nationals on the process (14) • Involvement of nongovernmental sectors, partners, and donors in the JEE to subsequently facilitate the development, financing, and implementation of plans of action (8) • Assigning a core national team for the preparations and follow up made conducting the JEE easier (1)
	JEE Tool • Proper translation of the French version of the tool (2) • A guiding document/checklist for field visits to be annexed to the tool (2)
	National plan of action for health security • WHO to guide the development and costing of the plans of action (14) • WHO to facilitate and support all steps of development and costing of the plans of action (8) • Link the current short-term emergency response activities with long-term capacity-building activities based on the JEE outcomes (2)

Post-JEE National Action Plan

Although the EMR has made great progress in completing JEEs, there have been delays in developing a national action plan for health security (NAPHS). Only 3 countries have completed their NAPHS (Pakistan, Morocco, and Jordan). Some of the reasons for this delay include delays in developing the guidance and templates for the NAPHS process and tools for developing and costing it. Additionally, there has been a lack of availability of trained staff to facilitate the development of the NAPHS, and some countries have lacked the ability to organize and coordinate a multisectoral and multiregional approach to get support and “buy-in” on what needs to be included in the NAPHS. Even so, progress has been made, and 6 countries (Lebanon, Qatar, Bahrain, Saudi Arabia, Oman, and United Arab Emirates) have started implementing priority actions identified under the JEE and are in the process of developing a NAPHS. At present, provision of guidance to member states is under way to facilitate the country-led, country-driven, and country-owned process of developing NAPHSs.

Discussion

The Eastern Mediterranean Region is composed of 21 IHR states parties, with an estimated total population of 644 million (8.6% of the world population in 2016).²⁷ Since 2011, the EMR has witnessed unprecedented levels of political turmoil and armed conflict. Almost two-thirds of the region's countries are directly or indirectly affected by emergencies, including 4 countries (out of a total of 6 globally) that are graded by WHO and the United Nations as experiencing “major” emergencies (grade 3): Syria, Iraq, Yemen, and Somalia.²⁸ The region also has countries witnessing protracted emergencies, including Afghanistan, Lebanon, Libya, Pakistan, Sudan, and Palestine. Most of the remaining countries are affected by crises in neighboring countries. Additionally, the region has had significant outbreaks, such as of MERS-CoV, which have affected not only countries in the region but also countries in other regions, making it critical for the EMR countries to build capacity to prevent, detect, and respond to such events at their source.

The IHR M&EF has been developed to provide member states and partners with a tool to assess their progress on IHR implementation. Although voluntary, the JEE and its core features are central to this framework. The WHO office for the EMR led the JEE process and supported the majority of its member states to host it.

Lessons from the missions have shown that the JEE tools and process are threefold. First, the JEE is the right path for member states to achieve regional and global security. It conceptually fits national interests and political agendas in most parts and has consequently received an unconditional welcome in the EMR, as expressed in recent JEEs and by our survey. Exception exists at 2 levels: One lies in the perception by a few member states that the JEE may interfere with national security policies and with the classification of information; the other is associated with the technical and political difficulties in conducting the JEE in fragile states, such as those currently plagued by unrest and conflicts. In the former case, WHO EMRO is conducting, through its country office and representatives, the appropriate, reassuring diplomacy with these national authorities to mitigate any ill-perceived risk concerning JEE and to move them toward broad acceptance of the technical importance of conducting these exercises. For the latter, the WHO JEE secretariat and EMRO have developed, together with the CDC and other JEE partners, a detailed set of approaches to how the JEE can be implemented in fragile states. This guidance is being piloted and, once finalized, will be made available online at the WHO website.

Second, although eminently technical, the JEE carries some political sensitivities, and it requires government-wide acceptance. The momentum created by the RC63.2 Resolution has secured a broad span of political will across the EMR, and the high implementation rate of JEE in this region is a result of WHO EMRO's promptness in mobilizing all its resources before any shift in such will. Any delay in the conducting of JEEs in EMR countries would have jeopardized the overall achievement that has currently been attained.

Third, the JEE is a standardized process that can guarantee a quality outcome on a diversified, multifaceted, and complex national health policy agenda. Constant attention to member states' national sensitivities and context has resulted in consistently positive feedback, more specifically highlighting the benefit of JEE's multisectoral approach, which gives national experts a unique opportunity to meet and work together for a public health goal.

Limitations

While this study provides support for the JEE process in the EMRO region and clearly demonstrates the added value of the JEE in furthering progress toward meeting IHR commitments in the 14 countries, some issues potentially limit its generalizability to all countries in the region.

First, not every country in the region has yet completed a JEE. Several of the remaining countries are currently facing ongoing conflict and humanitarian crises and other sociopolitical challenges that make completing a JEE difficult or impossible at this time. The researchers determined that the information contained in this article is valuable in and of itself and that publication should not be delayed indefinitely in order to await completion of JEEs in all EMRO countries. Efforts are ongoing to support the completing of JEEs in these remaining countries as soon as practicable, and studies are planned to assess JEE's value added in this unique subset of countries, as well as the particular challenges of completing the JEE process in countries undergoing active conflict and humanitarian response.

Second, the wording of the survey questions, particularly question 1 (“What is the added value of the JEE?”), potentially introduces bias into the responses by presupposing that the JEE does, in fact, provide added value. This was mitigated, in part, by including additional questions that provide responders an opportunity to address limitations and areas of improvement for the JEE process.

Conclusion

The WHO EMRO with the support of partners will continue to support the remaining 7 member states to host JEEs. A different approach for conducting the JEE will be followed for 4 member states that are currently in crisis (ie, Iraq, Libya, Syria, and Yemen); however, the same JEE process and tool will be maintained.

In a subset of countries, country-led, country-driven, and country-owned NAPHSs are being developed that address the identified gaps and build on existing relevant plans. Costing these plans has also been initiated, and the WHO objective is to support this process in all countries that conduct JEEs. The financing of such plans remains a huge challenge and a major potential impediment to future progress. Also, national commitment to allocate domestic resources and coordination and collaboration with partners to mobilize external resources to the developing countries with a proper mechanism in place to monitor and evaluate the implementation of these plans at all steps still need to be addressed. The occurrence of public health events and the capacity of member states to manage and respond to these events will determine how well member states progress in implementing IHR capacities and whether the IHR M&EF, including the JEE, have added value in enhancing the public health capacities of member states.

Footnotes

Acknowledgments

The authors wish to acknowledge the leadership of its member states in the Eastern Mediterranean Region for volunteering for JEEs and their commitment to implementing and addressing gaps identified through their own resources as well as partners with international agencies and public and private donors. We also recognize the guidance and support received by the WHO JEE secretariat as well as from the US Department of Health and Human Services, the US Centers for Disease Control and Prevention, the US Department of Agriculture, the Food and Agricultural Organization of the United Nations, the Organization for Animal Health, and the government of Finland. We express our appreciation to the national IHR focal points in EMRO, as well as to the subject matter experts who have participated and contributed to JEEs in EMRO.

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