Health Security Planning: Developing the Cameroon National Action Plan for Health Security

Abstract

The health security planning process transforms recommendations from various evaluations into priority actions to strengthen countries' capacity for emergency preparedness using the One Health approach. Although the World Health Organization (WHO) has developed many tools to facilitate the planning process of a National Action Plan for Health Security (NAPHS) across the various components, a series of multisectoral workshops is still needed to complete the process. In this article, we report on the process of developing Cameroon's NAPHS and propose an innovative solution to improve the process. The NAPHS development process was conducted from May to December 2018. The WHO NAPHS framework, adapted to the local context, guided the process. The WHO planning matrix was used to plan activities and the WHO NAPHS costing tool was used to facilitate the costing exercise. A total of 84 Joint External Evaluation recommendations were translated into activities included in Cameroon's NAPHS. Among these activities, the majority (56%) were of medium priority. The total cost of a 5-year NAPHS was US$87,668,356, with almost half (49%) of the budget allocated to activities in the “Prevent” category and more than a third (35%) allocated to the “Detect” category. The top 3 cost drivers were immunization (22%), the national laboratory system (21%), and antimicrobial resistance (16%). The NAPHS informed policymakers of planned activities and funding needs to fast-track the development of health security capacities. Running gaps in funding will be addressed during a resource mapping exercise. To improve the overall planning process, a web-based support solution, where stakeholders select from a menu of recommendations from the Joint External Evaluation to develop a NAPHS, should be developed to improve the NAPHS development process.

Background

Countries need to continuously establish, develop, strengthen, and maintain their evidence-based capacities to prevent, prepare for, detect, notify, and respond to public health emergencies. This has been highlighted by lessons learned from Ebola virus disease,^1,2 Zika virus disease,³ the COVID-19⁴ pandemic, the monkeypox outbreak,⁵ and other recent health emergencies. In Cameroon, major health emergencies have been driven by outbreaks of measles, wild type poliovirus, cholera, avian influenza, monkeypox, and COVID-19. The country's capacity to address these health emergencies was assessed during the Joint External Evaluation (JEE) of the International Health Regulations (2005) (IHR) conducted in 2017.⁶ Key findings revealed that Cameroon had limited capacity to address public health emergencies (score of 2 on a scale of 1 to 5). The country's capacity to prevent public health emergencies scored the weakest in the technical areas of national legislation and financing, antimicrobial resistance, and biosafety and biosecurity. In its capacity for early detection of health threats, the country's national laboratory system and reporting were identified as the weakest technical areas. To help the country efficiently respond to health emergencies, the areas of greatest need were identified as (1) emergency preparedness, (2) emergency response operations, and (3) medical countermeasures and personnel deployment. With regard to other IHR-related hazards and points of entry, the greatest need identified was strengthening chemical events response system and IHR capacities at points of entry.⁵

Cameroon is signatory to the IHR, which was adopted in 2007 by 196 World Health Organization (WHO) member states and other state parties as the essential vehicle for addressing global health emergency issues, while avoiding unnecessary interference with international traffic and trade.⁷ As a mandatory requirement of the IHR, in 2010, Cameroon designated the National Public Health Observatory (NPHO) as its IHR national focal point. The core mandate of the NPHO is to provide evidence-based decisionmaking on public health issues. The NPHO sits in the Office of the Prime Minister and is classified as a specialized technical body of the Ministry of Public Health. In addition to the JEE, simulation exercises and after-action reviews are regularly conducted in Cameroon to test the functionality of the country's emergency preparedness and response system. These processes generated considerable data at the global and country level.

In 2019, the WHO JEE Secretariat recommended that states parties should use their IHR Monitoring and Evaluation Framework data to inform the development of a National Action Plan for Health Security (NAPHS) for health security capacity building.⁸ The NAPHS process is described as “a country-owned, multi-year, planning process that can accelerate the implementation of IHR core capacities and is based on the One Health and whole-of-government approach for all hazards”^9,10 including nonhealth sectors⁸ and civil society. However, the NAPHS development process is lengthy and time consuming. For example, Lee et al¹¹ found that in Nigeria, the NAPHS costing effort alone required about 2,700 person-hours for participants and 2 person-hours for the costing expert to complete the costing process using the WHO NAPHS costing tool.¹² Although WHO has developed many tools to facilitate the planning process of the NAPHS across the various areas, a series of multisectoral workshops are also needed to complete the process.¹³ In this article, we describe the process of developing the Cameroon NAPHS and propose an innovative solution to improve the process.

Methods

Participants

The contribution of different disciplines, sectors, and areas of work, joining forces through a One Health approach, is essential for implementing the IHR.¹⁴ Four technical working groups were constituted and maintained throughout the NAPHS development process.⁵ The groups were organized into 4 thematic areas of the JEE: prevent, detect, respond, and points of entry and other hazards. Members of the technical working groups came from line ministries involved in IHR implementation in the country. These technical working groups were composed of JEE technical area leads and other stakeholders involved in the implementation of the NAPHS activities.

NAPHS Development Process

The NAPHS development process took about 2 years, from situational analysis to costing. It started with the JEE assessment in September 2017, during which key recommendations to strengthen health security were formulated,⁵ and ended with the cost estimation exercise in December 2018. In the inception phase, a SWOT (strength, weakness, opportunity, and threat) analysis was not conducted and technical areas were not prioritized. All JEE recommendations within the 19 technical areas were translated into detailed activities in the NAPHS, with the recommendations prioritized over the 5 years of implementation. A resource mapping exercise was conducted during the implementation phase, rather than the development phase, which is indicated by the NAPHS framework.¹⁰ In addition, no high-level steering group was established in Cameroon to provide strategic direction to the planning process as suggested in the NAPHS framework. The entire process was led by the IHR national focal point team who conducted the stakeholder analysis at the beginning of the JEE process, rather than the inception phase, which enabled the identification of key stakeholders earlier in the NAPHS development process.

Tools

During the NAPHS development process, the country adapted the WHO NAPHS framework¹⁰ to the local context (Table 1). The framework is a flexible, 3-step approach developed to facilitate multisectoral planning and implement priority actions to attain health security. Step 1 (inception) consists of conducting a desktop review of all existing national plans and capacity assessments, a stakeholder analysis, and a SWOT analysis, and prioritizing technical areas. Step 2 (development) consists of identifying and prioritizing activities based on a risk assessment, the monitoring and evaluation framework, activity costing, resource mapping, and endorsement of the NAPHS. Step 3 (implementation) consists of reprioritizing the plan based on resource mapping, integration into national sectors plans, monitoring and evaluation, and periodic review and updating of the NAPHS. This step also includes implementation of the NAPHS and continued mobilization of additional resources.^9,10

Table 1.

Adapted NAPHS Framework

Phases	Inception	Development	Implementation
Key activities	Review of existing capacity assessments (JEE conducted in 2017, performance of veterinary services conducted in 2011) Review of existing plans (Health Sector Strategy 2016-2027,¹⁵ the National Health Development Plan 2016-2020,¹⁶ the 2012 National “One Health” Strategy,¹⁷ the Animal Health and Veterinary Public Health Policy Document 2018,¹⁸ the Human Resources for Health Development Strategic Plan 2019-2023,¹⁹ comprehensive multiyear immunization program²⁰) Review of country risk profiling (Threats and Hazards Identification and Risks Assessment²¹ conducted in 2017) Prioritization of strategic actions	• Monitoring and evaluation framework development • Technical validation • Costing	• Reprioritization for • Implementation (Annual plan) • Integrating into line ministries annual work plan • Mapping of resources • Monitoring and evaluation • Periodic review and update
Outputs	Situation analysis of country context	• Finalized and costed NAPHS	• Plan implemented • Monitoring and evaluation • Resource mapping

Abbreviations: JEE, Joint External Evaluation; NAPHS, National Action Plan for Health Security.

The WHO planning matrix⁹ was used for the planning of activities and the WHO costing tool¹² was used during the cost estimation exercise. The estimated cost for each activity was obtained from aggregates of the individual activities. Before using the tool, the in-country planning department of the Ministry of Public Health populated basic inputs. These inputs include the exchange rate, costs for national and international consultants, per diem for nonresident and resident participants, vehicle and meeting costs (eg, hall rental, tea break, lunch, stationery, facilitator costs), and per diem and vehicle costs for field visits. Activities were grouped into 5 categories for costing: (1) human resources, (2) procurement, (3) field visits, (4) meetings, workshops, and trainings, and (5) consultancies. For human resources, participants specified the title of the position, the duration of the recruitment, and the monthly salary. For unit costs for procurements, the government procurement directory was used; where data were not available, other international documents, such as WHO procurement references, were used according to guidance provided by WHO costing experts. For supervision and field visits, participants indicated the number of supervisors and the duration.¹⁴ For meetings, workshops, and trainings, participants provided the number of days and the number of resident and nonresident participants and facilitators. For consultancies, inputs specified whether the consultant was a national or international, the duration of the consultancy, and any necessary travel costs associated.

The stakeholder's analysis and mapping was conducted using the Power-Interest grid proposed by Eden and Ackermann.²² The parameters used for stakeholder mapping were: (1) level of interest, determined by how much a stakeholder cares about the outcomes, if they are beneficiaries, or if there will be negative effects; and (2) level of influence, determined by the degree to which a stakeholder could make or break the project, such as through funding, legislation, and protests. A stakeholder analysis matrix provided a visual representation of the importance of stakeholders and the engagement strategy that is useful for each group of stakeholders.

The WHO prioritization matrix was used to identify priority actions and streamline the planning process using a rating system based on selected weighted criteria.⁹ The 8 criteria used in Cameroon were: (1) consistency with previous assessments (eg, JEE, Performance of Veterinary Services,²³ simulation exercises, after-action reviews), (2) impact on strengthening health security, (3) speed of implementation with limited resources, (4) existence of an advocacy champion, (5) level of priority for the technical area, (6) need for additional resources, (7) availability of resources, and (8) linkages with existing plans. Priority actions were ranked based on the total scores, and results were discussed. Strategic actions with scores between 1 and 4 were categorized as “low priority,” those with scores between 4 and 8 were categorized as “medium priority,” and scores between 9 and 12 were classified as “high priority.”

No ethical clearance was required for this study as it posed no risk of harm to humans and animals. The Ministry of Public Health provided administrative clearance and sent letters inviting stakeholders to attend the various workshops. The stakeholders, in turn, were designated as official representatives and provided with an official letters by their senior management, which enabled them to attend the planning process.

Results

NAPHS Development Timeline

The NAPHS development process was conducted during a series of workshops, with an average of 35 participants per workshop (Figure). The process was completed within 2 years, from JEE to costing. However, the JEE recommendations started to be addressed before the first NAPHS development phase and they continued throughout the NAPHS process. The first review was conducted after 3 years and the official launch is still pending.

Figure. Timeline of the National Action Plan for Health Security development in Cameroon.

Stakeholder Mapping

The stakeholder mapping activity began before the self-assessment of the IHR capacities and continued as new stakeholders were identified during the NAPHS development process. The outcomes of the stakeholders mapping activity are presented in a matrix that groups stakeholder organizations according to their influence and interest in the NAPHS (Table 2). We found that politicians, parliamentarians, and Ministry of Finance officials were identified as high-influence but low-interest stakeholders (Table 3). It is important to mention that not all stakeholders were engaged in all the phases of the NAPHS development process; for example, embassies were engaged only during the resource mapping phase.

Table 2.

Stakeholders Involved in the NAPHS Development Process in Cameroon

Technical Areas	Stakeholders
National legislation, policy, and financing	MPH
IHR coordination, communication, and advocacy	MLFAI, MPH
Antimicrobial resistance	FAO, IDDS, MENPSD, MLFAI, MPH, WHO
Zoonotic disease	FAO, MLFAI
Food safety	ASF, MLFAI, MPH
Biosafety and biosecurity	CPC, IDDS, MENPSD, MLFAI, MPH, NVL
Immunization	MLFAI, MPH
National laboratory system	CPC, MENPSD, MLFAI, MPH, MSRI, NVL
Surveillance	MLFAI, MPH
Reporting	MLFAI, MPH, WHO
Human resources	CDC, FAO, MLFAI, MPH
Emergency preparedness	MPH
Emergency response operations	MPH
Linking public health and security authorities	MLFAI, MOD, MPH
Medical countermeasures and personnel deployment	MPH
Risk communication	MPH
Points of entry	MLFAI, MPH
Chemical events	MARD, MENPSD, MITD
Radiation emergencies	NARP

Abbreviations: ASF, Agency for Standards and Quality; CDC, US Centers for Disease Control and Prevention; CPC, Centre Pasteur du Cameroun; FAO, Food and Agriculture Organization of the United Nations; IDDS, infectious disease detection and surveillance; IHR, International Health Regulations; MARD, Ministry of Agriculture and Rural Development; MENPSD, Ministry of Environment, Nature Protection and Sustainable Development; MITD, Ministry of Industries and Technological Development; MLFAI, Ministry of Livestock, Fisheries and Animal Industries; MOD, Ministry of Defense; MPH, Ministry of Public Health; MSRI, Ministry of Scientific Research and Innovation; NARP, National Agency for Radiological Protection; NVL, National Veterinary Laboratory; WHO, World Health Organization.

Table 3.

Stakeholder Mapping Matrix

SATISFY	MANAGE
High Influence, Low Interest	High Influence, High Interest
Politicians, Parliament, Ministry of Finance	Prime Minister's office, ministries (health, agriculture, environment, defense, research, higher education), National Agency of Radiation, partners (World Health Organization, US Centers for Disease Control and Prevention, World Bank, Metabiota, Clinton Health Access Initiative, Helen Keller International, International Medical Corps)

MONITOR	INFORM
Low Influence, Low Interest	Low Influence, High Interest
Embassies, private sector	Health personnel, civil society, media

Prioritization of JEE Recommendations

During the inception phase, the WHO prioritization matrix⁹ was a useful tool that facilitated prioritization of the JEE recommendations. A total of 84 recommendations were formulated during the JEE. The majority of JEE recommendations were scored as medium-priority activities (56%), followed by high-priority activities (42%), and low-priority activities (2%). All JEE recommendations were translated into activities in the NAPHS, and high-priority activities were programmed for the first year of the NAPHS implementation and served as the basis for identification of necessary resources during the resource mapping exercise.

Cost Estimation of the NAPHS

The WHO costing tool¹² contributed to estimating the cost of detailed activities across all 19 technical areas of the JEE. The exercise was intense and took about 5 days to complete. The cost disaggregation of the NAPHS is presented in (Table 4).

Table 4.

Cost Disaggregation per Thematic Area

Thematic Areas	Total Cost (FCFA)^a	Total Cost (US$)^b	% of Total Budget	Cost per Person per Year (US$)^c
Prevent	23,641,694,000	43,002,460	49.05	0.323
Detect	16,909,416,000	30,756,953	35.08	0.231
Respond	2,656,659,000	4,832,262	5.51	0.036
Other IHR-related hazards and points of entries	4,990,136,000	9,076,681	10.35	0.068
Total for 5 years	48,197,905,000	87,668,356	100	0.658

The Central African Franc (FCFA) is the local currency used in Cameroon. ^bExchange rate: US$1 = 549,775 FCFA (as of February 24, 2021). ^c2020 World Bank estimated population at 26,545,864 people.²⁴ Abbreviation: IHR, International Health Regulations.

The total cost of the Cameroon's NAPHS was estimated at US$87,668,356 for 5 years. The largest portion of the budget was allocated to prevention of public health emergencies (49.1%), followed by the detection of health threats (35.1%) (Table 3).

The top 3 cost drivers of the NAPHS are presented in (Table 5). Immunization accounts for 22% of the total budget for the NAPHS, follow by the national laboratory system, which accounts for 21%.

Table 5.

Disaggregation of the Cost of Cameroon's NAPHS by Technical Area

Technical Areas	Cost in (FCFA)^a	Cost (US$)^b	% of Total Budget
National legislation, policy, and financing	251,365,000	457,218	0.5
IHR coordination, communication, and advocacy	310,895,000	565,500	0.6
Antimicrobial resistance	7,675,636,000	13,961,540	15.9
Zoonotic disease	3,154,610,000	5,738,054	6.5
Food safety	169,004,000	307,409	0.4
Biosafety and biosecurity	1,501,690,000	2,731,488	3.1
Immunization	10,578,494,000	19,241,672	21.9
National laboratory system	9,956,100,000	18,109,573	20.7
Surveillance	4,201,524,000	7,642,330	8.7
Reporting	69,353,000	126,149	0.1
Human resources	2,682,439,000	4,879,202	5.6
Emergency preparedness	264,159,000	480,490	0.5
Linking public health and security authorities	148,940,000	270,913	0.3
Emergency response operations	748,807,000	1,362,037	1.6
Medical countermeasures and personnel deployment	289,264,000	526,155	0.6
Risk communication	1,205,489,000	2,192,715	2.5
Points of entry	3,764,795,000	6,847,946	7.8
Chemical events	446,246,000	811,696	0.9
Radiation emergencies	779,095,000	1,417,129	1.6
Total	48,197,905,000	87,669,216	100

The Central African Franc (FCFA) is the local currency used in Cameroon. ^bExchange rate: US$1 = 549,775 FCFA (as of February 24, 2021).

Discussion

The United Nations High-Level Panel recommends that costed NAPHS should be completed within 3 months of completing the JEE.²⁵ However, the implementation of this recommendation varies from country to country. Nigeria¹¹ and Tanzania¹² completed the NAPHS development process within 1 year, whereas Cameroon required 2 years to complete the process. The reasons for the longer time period were weak political engagement, lack of financial resources to convene the stakeholders to the multiple workshops, and lack of trained personnel in program management for the NAPHS. However, the time from the JEE until NAPHS completion was shorter between Cameroon (8 months) and Nigeria (6 months).²⁶ This is an acceptable timeframe compared with the general trend observed in the literature. Indeed, the median time from JEE to NAPHS completion was found to be 364 days (interquartile range: 266 to 497 days)¹¹ for countries that completed the NAPHS. However, delaying development of the NAPHS can lead to a loss in momentum for the multisectoral collaboration²⁶ triggered by the JEE.⁵ 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. In addition, the unavailability of trained staff to facilitate the development of the NAPHS was also reported. Some countries have lacked the ability to organize and coordinate a multisectoral approach to obtain support and ‘‘buy-in’’ on activities to be included in the NAPHS.²⁷ Even so, countries have started implementing prioritized actions identified under the JEE during the process of developing the NAPHS.²⁶ The same situation was observed in Cameroon.

With regard to the multisectoral engagement, multisectoral technical working groups have been established in Cameroon, Tanzania,¹² and Nigeria¹¹ at the national level and at federal and provincial levels in Pakistan.²⁷ This enabled joint identification of the most urgent needs within the health security system during the NAPHS development process¹² and facilitated the establishment of an efficient, alert, and responsive systems for effective implementation of the IHR.²⁹ In addition, it provided a platform for prioritization of opportunities to enhance preparedness and response and for engagement with current and prospective donors and partners to effectively target resources.¹²

Bringing together multiple government sectors, partners, and donors highlights the need for a high-level coordination platform to map and ensure collaboration between the sectors involved.¹² The absence of a NAPHS coordination platform in Cameroon weakened the monitoring and evaluation process of the activities. Indeed, the first monitoring workshop was conducted about 3 years after the NAPHS was developed because of the absence of a high-level coordination and accountability mechanism, the lack of a specific tool to guide the country in the monitoring process, and lack of a dedicated team responsible for tracking and reporting the progress on a regular basis. It has been documented in the literature that the establishment of quarterly multisectoral coordination meetings for planning and monitoring progress further improves trust and multisectoral coordination.³⁰ This can also provide space for proactive positioning of available scarce resources from specific programs into sector-wide development of health systems to address all hazards¹¹ especially when dealing with an environment where line ministries are familiar with conflicts of interest and protectionism of resources.³⁰ In Tanzania, for example, the One Health Coordination Desk and interministerial steering committee through the Department of Disaster Management, located in the Office of the Prime Minister, was identified to ensure effective coordination of the NAPHS activities that fall under the mandate of different ministries.^12,31 In Pakistan, the Multisectoral National Taskforce for IHR was appointed to oversee the NAPHS development process. Additionally, to ensure subnational active participation, IHR task forces were formed by and for each province.²⁸

Concerning stakeholder management, high-influence and low-interest stakeholders, such as Parliament and the Ministry of Finance, were not involved in the NAPHS development process from the beginning. This situation led to poor political engagement and difficult mobilization of the resources for the implementation of the NAPHS. Nevertheless, the NAPHS objectives were aligned to their objectives to satisfy them and ensure they remain strong advocates. Indeed, using among others national strategic documents and sectoral plans such as the human and animal health sectors strategic plan during the NAPHS development to guide the definitions of priorities helped to achieve that purpose.¹⁴

Stakeholders with little influence and interest were occasionally involved during specific activities of the NAPHS development process. For example, embassies and the private sector were key stakeholders involved in the NAPHS resource mapping workshop to capture their current and future support in the NAPHS activities. This ensured that they remain at the forefront of their involvement as their interest and influence may change over time.

Stakeholders with a strong influence and interest were closely involved in the development and implementation of the NAPHS activities. Key ministries that address issues related to health, animals, environment, and defense are also members of the IHR national focal point team. This approach helped the country build strong relationships with these stakeholders and ensure that their support is maintained. They are involved in decisionmaking and are regularly consulted.

Stakeholders with little influence but strong interest are the main beneficiaries of NAPHS activities. Civil society, for example, was belatedly involved during the monitoring and review of the NAPHS, because they had been left out of the initial stages of NAPHS development. This situation resulted in poor ownership of activities at the community level. However, they are now consulted much earlier in their areas of intervention and their contributions are used to improve the chances of success of the NAPHS.

Cameroon, Nigeria, and Tanzania all used a priority matrix approach to rank the NAPHS actions. The number of criteria varied from one country to another. A total of 6 criteria were used in Tanzania,¹³ 8 in Cameroon, and 4 in Nigeria.¹¹ Similar criteria in Cameroon and Nigeria included known advocates and easily achieved objectives. Ongoing activities and critical areas for capacity development were used in Nigeria only.¹⁰ After the prioritization exercise, the technical working groups pulled out specific activities for implementation in the first 2 years of the NAPHS implementation in Nigeria.¹¹ In Cameroon, a Year 1 operational plan was developed 3 years after the costing workshop; the delay was due to health security not being considered a high-priority program in the Ministry of Public Health's agenda, insufficient financial and technical resources, and lack of a specific tool. Indeed, the literature revealed that planning for years 3 to 5 would depend predominantly on results from the first 2 years.²⁶

Although Cameroon only used the recommended WHO costing tool¹² to cost NAPHS activities, other available tools can be used. In Nigeria, for example, 2 other costing tools were used after the NAPHS was costed with the WHO costing tool. These tools included the Georgetown University IHR costing tool³² and the US Centers for Disease Control and Prevention Priority Actions Costing Tool (PACT), which used the JEE scores and priority actions as inputs.¹¹ Despite producing similar estimates, the costing efforts varied considerably. The WHO costing tool requires much more person-hours to complete the exercise than either of the 2 activity-based costing tools.¹¹ In early 2017, Pakistan developed its own tool using Microsoft Excel for costing of the NAPHS, with the assistance of health economists and costing experts, as there were no standard WHO costing tools available at that time.²⁸

The national laboratory system was one of the top cost drivers in both Cameroon and Nigeria, regardless of the costing tool used. In addition, workforce development, preparedness, surveillance, and reporting were the major cost drivers by technical area for the Nigeria NAPHS.¹¹ Using the IHR costing tool, the other major cost drivers were preparedness, surveillance, and reporting. Surveillance and reporting were the major cost drivers using PACT.¹¹ In Tanzania, emergency preparedness, emergency response operations, linking public health and law enforcement, medical countermeasures, and risk communication were found to drive the cost of the NAPHS.¹³ When comparing the cost drivers and the JEE scores, we noted that Cameroon will spend the highest budget of the NAPHS to strengthen the country's capacities on immunization, where the country already records developed capacities (score = 3). Whereas less budget will be invested to establish an antimicrobial resistance surveillance system where the country recorded no capacities (score = 1). The NAPHS output estimates the total cost of Cameroon's NAPHS to be about US$87.6 million for 5 years (approximately US$0.658 per person per year). This was approximately the same total cost for the Tanzania NAPHS (US$86.6 million),¹³ but the cost per person per year was higher in Tanzania (US$289 per person per year).

When we disaggregate the cost by thematic area, the cost for “Prevent” in Cameroon was found to be double that of Tanzania (US$43 million vs US$22 million), but lower in terms of cost per person per year in Cameroon (US$0.32) compared with Tanzania (US$73.6). The total cost for “Detect” was found to be higher in Tanzania than Cameroon (US$30.7 million vs US$50 million) and the cost per person per year (US$16.7 vs US$0.23). For “Respond,” the total cost was higher in Cameroon than Tanzania (US$5.8 million vs US$4.8 million), but lower in Cameroon than Tanzania when we consider the cost per person per year (US$0.036 vs US$16). A similar cost of US$9 million was reported for “Other IHR Hazards and Point of Entry” in both countries,¹³ but the cost per person per year was found to be higher in Tanzania (US$30.8) than in Cameroon (US$0.068).

Although the overall cost of the NAPHS is relatively similar in both countries, the cost per person per year is less in Cameroon than Tanzania (less than US$1). Studies have identified the financing of outbreak preparedness and response as one of the most important challenges facing policymakers in low-income countries with limited resources and complex political environment.^33-35 However, ensuring sustainable funding for the implementation of the NAPHS is critical for strengthening health security capacities in the country. The government should therefore identify financing strategies by allocating its own resources^28,29 to finance this high-quality integrated plan. In Cameroon, for example, the national budget allocation to improve the healthcare systems has been around 5% for a decade, despite African Union member states committing to allocate at least 15% of their national budgets each year to the health sector. However, the government's Health Sector Strategy 2016-2027 aims to gradually increase this allocation to 10.1% by 2027.¹⁵ This trend can be justified by the increasing gross domestic product and economic growth predicted for the period of 2016 to 2027.³⁶ The estimated cost of the health sector strategy is more than US$10 billion over the 12-year period (ie, an average annual cost of over US$5 billion), and the health system strengthening pillar will absorb the largest portion (48%) of the budget. Of this total budget, the estimated budget allocation for subcomponent emergencies, disasters, humanitarian crises, and public health events (including surveillance and response to epidemic-prone diseases and zoonosis) is about US$224 million for 12 years, which has room to finance the US$87.6 million required for the NAPHS for 5 years.

In 2020, Cameroon adopted the National Development Strategy 2020-2030 (NDS 30),³⁷ which is the new reference framework for development efforts over the next decade. The Health Sector Strategy 2016-2027 will have to be revised to align it with this new strategy.¹⁵ This provides a unique opportunity to consider the health security priorities outlined in the NAPHS. However, supplementary donor financing to low-income, high-risk countries subjected to humanitarian crisis might still be needed.³⁸ Based on cost estimates for pandemic preparedness from 24 NAPHS, an estimation of approximately US$9 billion to US$10 billion is needed for 3 years for the whole of the WHO African region. This translates into US$2.50 to US$3.50 per person per year, therefore making the investment case for emergency preparedness an affordable public health good.²⁹ As an example, in 2020, the Cameroon government invested about US$364 million to respond to the COVID-19³⁹ pandemic, which represents about 4 times the estimated cost of the NAPHS in 5 years. After this exercise, no specific action was taken by the Cameroonian government to mobilize necessary funding for the implementation of the NAPHS. Meanwhile, a concerted effort was made in Tanzania to identify domestic funding to supplement with funding from partners; in addition, the country launched the NAPHS at a parliamentary session to ensure that parliamentarians were aware of the plan and could advocate for increased domestic funding from the public and private sectors.¹³

Lessons Learned

The NAPHS development process in Cameroon generated lessons learned that could be leveraged for the success of the next health security plan using the third edition of the JEE tool⁴⁰:

To ensure maximum high-level political and multisectoral buy-in for the delivery of the NAPHS, the identification of a responsible authority and the establishment of a high-level coordination platform is key to limit duplication of efforts and maximize synergies.

The definition of the role of relevant stakeholders in the health and nonhealth sectors and the establishment of an accountability helps to strengthen country-led consensus building to support the NAPHS implementation.

A trained and dedicated multisectoral team is crucial to ensure continuous tracking of the activities in the NAPHS.

Parliament and the Ministry of Finance should be involved from the beginning of the NAPHS development process to ensure they remain strong advocates in the interest of advocacy, financing, country ownership, effectiveness, and sustainability.

A strong relationship should be built between line ministries and partners to ensure that they retain support.

Communication should be established with embassies and the private sector to keep them informed and encourage their interest as their relevance may change over time.

Civil society and health personnel should always be involved to ensure the takeover of public health actions at the community level and ensure ownership and sustainability of health security.

Recommendations

Make all necessary tools available to countries, for use during all phases of the NAPHS development process (from inception to the monitoring and evaluation).

Develop a web-based support solution in which stakeholders select from a menu of JEE recommendations to improve the NAPHS development process and ensure regular tracking of the implementation of the activities.

Guide the country to develop a financing strategy for the NAPHS.

Include health security financing mechanisms in all national preparedness planning efforts, with endorsement and oversight by the Ministry of Finance, as part of a whole-of-government approach.⁴¹

Make the NAPHS available to potential partners and donors for support in addressing the gaps and provision of technical or financial assistance for implementation.¹⁹

Conclusion

The NAPHS development process in Cameroon was a long and intense journey. However, it created partnerships both across national sectors and with international partners. This momentum should be maintained by performing monitoring and reviews of the NAPHS on a regular basis to track progress. The NAPHS informed policymakers of the priorities, actions, and funding needed to fast track the development of health security capacities. Running gaps in funding or technical assistance will be addressed during the resource mapping exercise.

Footnotes

Acknowledgments

The authors would like to acknowledge the active contribution of national experts from technical departments of ministries of public health, livestock, environment, agriculture, communication, higher education, research, and territorial administration (Department of Civil Protection) defense, as well as the members of the international WHO team of experts. A special appreciation to Paul Schumacher for his great support during the costing exercise. The authors acknowledge country partners such as the WHO Cameroon country office, US Centers for Disease Control and Prevention, Food and Agriculture Organization of the United Nations, Tackling Deadly Diseases in Africa project, United States Agency for International Development country office through the Infectious Disease Detection and Surveillance project for technical guidance provided throughout the planning process.

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