Development of a Subnational Health Security Capacities Assessment Tool: Lessons From Nigeria and Implications for the Implementation of the Integrated Disease Surveillance and Response Strategy

Abstract

The Joint External Evaluation tool is a World Health Organization-recommended method for evaluating countries’ capacities under the International Health Regulations (2005) (IHR). It encompasses a national preparedness assessment process for public health threats and offers a structured framework for planning and implementing effective response measures. A tailored approach is necessary for Nigeria’s federated system of government, in which most constitutional requirements for public health and associated issues are decentralized to the state level. The Nigeria Centre for Disease Control and Prevention (NCDC) developed an assessment tool to identify state-level health security gaps and support the development of improvement plans. With input from state and national public health leaders and legal experts, a legislative evaluation was conducted to determine specific IHR activities that could be implemented within the state’s legal framework to accelerate the implementation of the Integrated Disease Surveillance and Response strategy and IHR. The resulting assessment instrument was piloted in Kano, Enugu, and Kebbi states, followed by a consensus meeting to identify additional areas for improvement. The revised tool contains 14 technical areas and 35 indicators tailored to implementing improvement plans. By recognizing the unique characteristics of subnational entities and their implications for pandemic preparedness, the tool provides an innovative approach to health security for countries with multilayered governance structures or geographic diversity. Conducting a subnational health security assessment is a crucial step in ensuring preparedness for public health threats and enhancing health security in Nigeria’s federated system of government.

Introduction

Existing health security capacity assessment tools, including the World Health Organization (WHO) Joint External Evaluation (JEE) Tool¹ and the Global Health Security Index,² measure capacities at the national level. Although some JEE indicators have subnational implications, a measuring system for subnational health security capacities that targets the appropriate implementing health authorities is not yet available.

The JEE constitutes an integral part of the International Health Regulations (2005) (IHR)³ and the IHR Monitoring and Evaluation Framework⁴; other components include the mandatory States Parties Self-Assessment Annual Reporting (SPAR),⁵ action reviews, and simulation exercises. The JEE was introduced in 2016 to address perceived shortcomings in the self-assessment process of the annual state reporting tool. Following the 2014-2016 Ebola outbreak in West Africa, multiple assessments of the SPAR acknowledged that this self-assessment instrument did not provide a reliable depiction of a nation’s epidemic and pandemic preparedness.^6,7 Thus, the transition from self-reporting to inclusive peer evaluation was adopted, leading to the introduction of JEE.

IHR implementation in the WHO African Region is based on the Integrated Disease Surveillance and Response (IDSR) strategy.⁸ The IDSR strategy facilitates efficient resource use by integrating and streamlining the surveillance, emergency response, and laboratory capacities required by the IHR. IDSR was endorsed by member states of the WHO Regional Committee for Africa in 1998 and commenced implementation in Nigeria in 2003.⁹ The goals of the IDSR strategy are to strengthen national capacity for early detection, complete recording, timely reporting, regular analysis, and prompt feedback of notifiable diseases, events, and conditions at all health governance levels; strengthen national laboratory capacity to confirm IDSR priority diseases, conditions, and events; and strengthen the capacity for emergency preparedness and response in public health at all levels.^10,11

The WHO African region member states have recognized that the IHR and the IDSR strategy share common goals. Both frameworks aim to strengthen the capacities to respond promptly to acute public health events, including early detection, verification, reporting, and response. In light of this recognition, member states in the WHO African Region declared¹² that IHR (2005) would be implemented through the existing IDSR strategy.

While national public health institutes and ministries of health are responsible for driving IDSR implementation nationally, efforts to generate results and institute the required health security capacities are expected at the subnational level—as provided for in the IDSR technical guidelines.^8,13

In 2017, Nigeria conducted its first JEE,¹⁴ followed by a 2019 country-led midterm assessment,¹⁵ using the second edition of the JEE tool).¹⁶ The midterm evaluation demonstrated some improvements across 11 out of the 19 technical areas. In addition, it highlighted the importance of subnational IHR strengthening.¹⁷ In a large, federated governance structure such as Nigeria’s, with 36 states and the Federal Capital Territory, the JEE and midterm JEE emphasized the critical need to strengthen subnational health security capacities; however, state-specific improvement plans could not be generated as states have authority for most of the contents of the JEE and IDSR.

The midterm assessment contributed to a growing interest in enhancing state-level IHR capacities. Recognizing the need for a targeted approach, the Nigeria Centre for Disease Control and Prevention (NCDC), serving as the national IHR focal point, devised an engagement strategy to strengthen subnational health security. Acknowledging the limitations of the JEE in providing precise baseline data at the state level, NCDC took the initiative to develop an assessment tool. This tool facilitates the identification of gaps in health security at the state level, empowering states to create strategic plans aimed at strengthening and operationalizing the necessary development plans for health security.

Accurate and detailed information is critical for state authorities to strategize and implement improvement plans efficiently. Applying the JEE tool does not capture the intricacies and diversities that are required at subnational levels, including strong health security governance platforms, budget and accountability frameworks, workforce, and health service provision. It is also essential to recognize that in Nigeria, the different levels of government operate within distinct budgetary processes.

In this article, we describe the development of a subnational IHR assessment tool in Nigeria, the process of validation and piloting, and lessons learned from its application, including informing the development of state-specific legislation and budgeting and planning processes.

Methods

Legal Assessment and Mapping

We conducted a national legal assessment and mapping of IHR implementation in Nigeria, which clarified the roles of the national and state levels and demonstrated that states possessed legal authority over health matters. The documents reviewed included the 1999 Constitution of the Federal Republic of Nigeria,¹⁸ IHR (2005),³ JEE 2nd edition assessment tool,¹⁶ the Rapid Urban Health Security Assessment (RUHSA) Tool,¹⁹ IDSR strategy,⁹ mapping analysis of IHR Implementation in Nigerian Law,²⁰ and related health security documents.^21-23 The powers to legislate and establish laws within Nigeria’s constitution are based on the exclusive, concurrent, or residual list. Only the federal government can legislate and establish laws on items on the exclusive list, whereas federal and state governments can establish laws on items on the concurrent list. The residual list, although not provided for in the constitution, captures the residue—that is, all that is not specified in the exclusive and concurrent lists. The state governments have authority to legislate on those issues.^18,20 Nigeria’s governance structure places health on the residual list. The residual list covers areas such as health service delivery, health financing, primary care, antimicrobial resistance, zoonotic diseases, food safety, immunization, laboratory systems and biosafety, environment, and surveillance.²⁰

Using findings from a desk review conducted by IHR experts, with contribution from state epidemiologists in Nigeria, we proceeded to adapt the JEE 2nd edition tool. During the development of the adapted subnational tool, a key priority was to ensure its alignment with implementation of the IDSR strategy, which is the foundation for the delivery of IHR core capacities.

Selection of Technical Areas Within State Jurisdiction in Nigeria

JEE technical areas were determined to be applicable to the subnational level based on their alignment with the constitutional allowance for these governance entities. This selection was guided by 3 qualitative indicators or critical questions: 1.

Is the technical area included in the residual list of the Constitution of Nigeria?

Do state governments have an existing legal mandate to provide a technical or financial contribution to implementing this technical area?

Is the technical area relevant at the state level, and is this considered a top priority as contained in the state strategic development plan for health?

Technical areas satisfying these criteria were included in the adapted subnational tool. For each technical area, indicators were also reviewed and adapted to the subnational level (eg, where a national plan was expected to be available). For example, if an indicator in the national tool requires the development of a national multihazard plan, the subnational tool would adapt this to require the development of a subnational multihazard plan instead.

The federated nature of Nigeria and the autonomous nature of states, coupled with the separation of powers among the 3 tiers of government (federal, state, local) as enshrined in the constitution, underscored the need to align the required IHR core capacities with the IHR requirement for such capacities to be developed at local (community), intermediate (state), and national levels.³

Stakeholder Engagement

We engaged stakeholders at global, national, and state levels to identify the technical areas within the JEE 2nd edition tool deemed pertinent for the states. We considered stakeholder engagement as actively soliciting judgment and knowledge from individuals directly interested in strengthening health security capacities in Nigeria and subsequently achieving IHR core capacity outcomes. These stakeholders were drawn from the NCDC leadership, state public health authorities, and subject matter experts from development partners who are experts in health security with a contextual background in the Nigerian public health system and had contributed to Nigeria’s JEE and the development and implementation of the National Action Plan for Health Security.²⁴ The project lead, a senior-level public health leader within the NCDC who was previously known to most stakeholders, and a consultant facilitated these engagements. Additionally, states were asked to identify champions to support advocacy efforts and lead stakeholder consultations, including implementation of the assessment tool and its integration in the assessment planning process. These champions were government-employed public health officers with the authority, technical expertise, and influence to operationalize the findings and garner support from other stakeholders, such as the director of public health and state epidemiologist.

We purposively selected participants from various organizations: NCDC (4), WHO (2), UK Health Security Agency (1), World Bank (1), US Centers for Disease Control and Prevention (2), Resolve to Save Lives (2), Kebbi State Ministry of Health (1), Enugu State Ministry of Health (1), and Kano State Ministry of Health (1). During the initial drafting of the assessment tool, we contacted these stakeholders via email and phone calls to identify the technical areas within the JEE 2nd edition tool that were considered pertinent and feasible for the states to finance and implement. Feedback from these stakeholders was synthesized by the project lead and the consultant and subsequently incorporated into the first draft of the assessment tool.

Scoring of Capacities

As with the JEE tool, scoring was designed on a 5-point colored scale, with specific color codes (red, orange, yellow, light green, dark green) assigned to each score (Table 1). The implementation status of each indicator is reflected by a score, which highlights the state’s level of advancement and its capacity to institutionalize technical area competencies to ensure that they are sustainable.²⁵

Table 1.

Subnational Health Security Assessment Tool Capacity Score Levels and Color Codes

Score	Color	Level	Description
1	Red	No capacity	Attributes of a capacity are not in place
2	Orange	Limited capacity	Attributes of a capacity are in the development stage (implementation has started, with some attributes achieved and others commenced)
3	Yellow	Developed capacity	Attributes of a capacity are in place; however, sustainability has not been ensured (such as through inclusion in the operational plan of the state health sector plan with a secured domestic funding source)
4	Light green	Demonstrated capacity	Attributes are in place and sustainable for a few years, which can be measured by the inclusion of attributes or IHR core capacities in the state health sector plan and a secured funding source
5	Dark green	Sustainable capacity	All attributes are functional and sustainable, and the state possesses the capacity to support 1 or more other states in their implementation—this is the highest level of achievement of implementation of IHR core capacities

Abbreviation: IHR, International Health Regulations (2005).

Validation of the Tool

The drafted subnational assessment tool was widely circulated among 15 government stakeholders and partners working on health security at both national and global levels (including WHO, the World Bank, the UK Health Security Agency, Resolve to Save Lives, and the US Centers for Disease Control and Prevention) for feedback. About 40% (n=6) of these stakeholders had previously participated in the stakeholder engagement. A subsequent 1-day tool validation meeting was held to ensure that the document accurately reflected the intended contents and the feedback received.

Three states—Enugu, Kano, and Kebbi—were purposively selected for the piloting of the subnational tool. Enugu and Kebbi states were chosen due to their early adoption of state public health emergency operations centers, supported by NCDC. They were selected to gain further insights into how these states were leveraging their public health emergency operations centers to strengthen emergency preparedness and response. Kano State was also included in the selection, being 1 of 6 states with an established polio emergency operations center. The inclusion of Kano aimed to provide a deeper understanding of the operations of the polio emergency operations center and to inform support to other states that have similar platforms.²⁶

Piloting of the Tool

Before deploying the tool to the states, a team of facilitators, who would act as national evaluators, were identified. A subsequent 1-day national training of trainers was conducted for the evaluators. A total of 15 national evaluators were trained in this session.

Pilot implementation was conducted in 2 phases: an initial advocacy and state-level training for self-assessment in the first phase and an external evaluation in the second. The advocacy initiative targeted political heads and decisionmakers from key government ministries, including the health, environment, agriculture, and finance, as well as development partners. This underscored the importance of embracing a unified One Health approach, which acknowledges the interdependencies among human, environmental, and animal health, even at the subnational level. Given the limited understanding of this approach to state-level public health response, this training helped raise awareness and garner support for integrating One Health principles into public health strategies. Subsequent state-level training was held to capacitate the state technical area leads to score and identify priority interventions.

The external assessment was conducted by a team of evaluators drawn from the NCDC and representatives from other government institutions responsible for IHR implementation and development partners. The assessment was done through a mixture of plenary sessions, including collegiate review of state submissions, evidence, and scoring. The facilitators guided the discussion as the state technical area leads presented the internal assessment findings, ensuring consensus was built and critical interventions were agreed upon to advance the technical areas.

Results

Overview of the Subnational Assessment Tool

We used the framework provided by the JEE 2nd edition tool to develop the subnational tool in order to ensure that state-level improvements contribute to the enhancement of national capacities. When considering the tools’ respective technical areas and the interventions recommended under them, we focused on assessing what fell within the state’s jurisdiction (see Table 2 for a comparison of technical areas of the 2 tools). The resulting tool has 14 technical areas, including 3 technical areas that were not present in the JEE 2nd edition tool from which the subnational assessment was adapted—financing, health security governance, and safer health facilities; the other 11 technical areas remained as obtainable in the JEE 2nd edition tool. The technical areas in the subnational tool are supported by 35 indicators (Table 3).

Table 2.

Comparison of the Joint External Evaluation 2nd Edition Tool and the Subnational Health Security Capacities Assessment Tool

Core Area	JEE 2nd Edition Tool Technical Area	Subnational Health Security Capacities Assessment Tool Technical Area
Prevention	National legislation, policy, and financing	Legislation, policy, financing
	IHR coordination, communication, and advocacy	Multisectoral coordination and health security governance
	Antimicrobial resistance	Safer health facilities (with infection prevention and control, case management, antimicrobial governance, and water, sanitation, and hygiene indicators)
	Zoonotic disease	Zoonotic disease
	Food safety	Food safety
	Biosafety and biosecurity	States do not have legal authority in this area
	Immunization	Immunization
Detection	National laboratory system	Laboratory system
	Surveillance	Surveillance and reporting
	Reporting	Surveillance and reporting
	Human resources	Human resources
Response	Emergency preparedness	Emergency preparedness
	Emergency response operations	Emergency response operations
	Medical countermeasures and personnel deployment	Medical countermeasures and personnel deployment
	Risk communication	Risk communication
	Linking public health and security authorities	States do not have legal authority in this area
IHR-related hazards and points of entry	Points of entry	States do not have legal authority in this area
	Chemical events
	Radiation emergencies

Abbreviations: IHR, International Health Regulations (2005); JEE, Joint External Evaluation.

Table 3.

Subnational Health Security Capacities Assessment Tool Technical Areas and Indicators

Core Area	Technical Area	Indicators
Prevention	Legislation and policy	P.1.1 The state has legislation, laws, regulations, policies, and administrative instruments in all relevant health security sectors and has assessed, adjusted, and aligned them to enable compliance with the IHR
	Financing^a	P.2.1 Financing is available for the development and implementation of health security capacities in the state on a routine basis
	Financing^a	P.2.2 Financing mechanisms and funds are available for the timely response to public health emergencies in the state
	Zoonotic disease	P.3.1 Coordinated surveillance systems are in place in the environmental, animal, and public health sectors for zoonotic diseases/pathogens identified as joint priorities
	Zoonotic disease	P.3.2 Mechanisms for responding to infectious and potential zoonotic diseases are established and functional
	Food safety	P.4.1 Surveillance systems are in place for the detection and monitoring of foodborne diseases and food contamination
	Food safety	P.4.2 Mechanisms are established and functioning for the response to and management of food safety emergencies
	Immunization	P.5.1 Vaccine coverage (measles) as part of state-level immunization program
	Immunization	P.5.2 State vaccine access and delivery
	Safer health facilities^a	P.6.1 IPC program as part of routine preparedness practice in health facilities
		P.6.2 Access to safe water in health facilities^a
		P.6.3 Case management capacity for health security-related events/ hazards
		P.6.4 Use of antimicrobial medicines is optimized
	Multisectoral coordination and health security governance^a	P.7.1 A functional multisectoral and health security governance mechanism is established for the coordination and integration of relevant health security sectors
Detection	Laboratory system	D.1.1 Laboratory testing for detection of priority diseases
		D.1.2 Specimen referral and transport system
		D.1.3 Effective diagnostic network and laboratory information systems
		D.1.4 Laboratory quality system
	Surveillance and reporting	D.2.1 Surveillance systems
		D.2.2 Use of electronic tools
		D.2.3 Analysis of surveillance data
		D.2.4 Reporting network and protocols are in place
	Human resources	D.3.1 An up-to-date multisectoral workforce strategy is in place
		D.3.2 Human resources are available to effectively implement health security activities
		D.3.3. In-service training is available
Response	Emergency preparedness	R.1.1 Strategic emergency risk assessments are conducted, and emergency resources are identified and mapped
	Emergency preparedness	R.1.2 State multisectoral multihazard emergency preparedness measures, including emergency response plans, are developed, implemented, and tested
	Emergency response operations	R.2.1 Emergency response coordination
		R.2.2 Emergency operations center capacities, procedures, and plans
		R.2.3 Emergency exercise management program
	Medical countermeasures and personnel deployment	R.3.1 System is in place for activating and coordinating medical countermeasures during a public health emergency
	Medical countermeasures and personnel deployment	R.3.2 System is in place for activating and coordinating health personnel during a public health emergency
	Risk communication	R.4.1 Risk communication systems for unusual/unexpected events and emergencies
		R.4.2 Internal and partner coordination for emergency risk communication
		R.4.3 Effective communication with communities

New or improved technical areas and indicators in the subnational assessment tool that are also included in the third edition of the World Health Organization Joint External Evaluation tool.

Abbreviations: IHR, International Health Regulations (2005); IPC, infection prevention and control.

We separated financing as a technical area to emphasize the critical role of operational and emergency funding in achieving an optimal state of health security at the subnational level. Additionally, it enabled us to conduct a focused evaluation of health security financing gaps.

We included the new technical area of multisectoral coordination and health security governance to assess and encourage the development of multisectoral governance platforms or reinforce existing state-level structures through the use of the One Health approach. The aim was to enable the implementation of and accountability for health security improvement plans in the state, as we have seen in Nigeria’s response to HIV, polio, and most recently COVID-19. The national government and several states established high-level ad hoc committees to drive these response activities. The national COVID-19 response in Nigeria, for example, was led by the secretary to the Government of the Federation, who headed a committee comprising 12 members, including 7 federal ministers.²⁷

Infection prevention and control (IPC) was not a dedicated technical area in the JEE 2nd edition, despite being a significant priority for preparedness and response. Instead, it was incorporated within the antimicrobial resistance technical area. This limited approach did not allow for a comprehensive evaluation of IPC, including crucial aspects such as healthcare-associated infection surveillance. This is especially pertinent given the recurring incidents of Lassa fever infections among healthcare workers (HCWs) in Nigeria over the years. During the 2019 Lassa fever outbreak, 19 HCWs contracted the virus, resulting in 2 deaths with a case fatality rate of 10%.²⁸ Hence, we created the technical area of safer health facilities to recognize lessons learned in Nigeria’s recurrent responses to epidemics.

The safer health facilities technical area was carefully articulated to stand alone; the aim was to reinforce the need to protect HCWs by enhancing IPC practices and ensuring that health facilities have access to and adhere to water, sanitation, and hygiene standards. The safer health facilities technical area encompasses indicators around IPC, use of antimicrobials, case management, and access to safe water in health facilities. The recent revision of the IPC technical area in the JEE tool was also a recognition of the important duty of protecting HCWs by providing adequate facility infrastructure to ensure the continuity of health services.¹ The third edition of the JEE now includes many of the technical areas in the subnational tool, as some of the stakeholders that had been engaged in the development of the subnational tool contributed to the JEE revision in 2021.²⁸ The daily provision of healthcare services exposes HCWs to significant risks, as exemplified by the inherent dangers they face. Numerous countries have reported that HCWs represented one of the groups most vulnerable to infection risks during the ongoing COVID-19 pandemic.^29-31

The IHR-related hazards and points of entry technical areas within the JEE tool (ie, chemical events, points of entry, radiation emergencies) were excluded from the subnational tool, as they are already evaluated in the national JEE and fall under the jurisdiction of federal authorities.²⁰ However, the federal government has, in practice, enacted legislation on the biosafety and biosecurity technical area even though it falls within the residual list where states theoretically hold legislative power.^32-34 States have not actively engaged with these issues through lawmaking, likely due to potential friction between national and subnational authorities, primarily attributed to national security concerns. Consequently, biosafety/biosecurity has predominantly remained under the jurisdiction of the federal government, leading to its exclusion from the subnational tool.

Lessons From Pilot Testing

Following the pilot, a process evaluation workshop was held to review lessons learned from the 3 states, which were then used to improve the subnational health security capacities assessment tool and develop subnational IHR benchmarks that align with the assessment tool. The subnational IHR benchmark was designed to mirror the WHO IHR benchmark by providing tailored, context-specific guidance for strengthening health security capacities at the subnational level.

WHO Benchmarks for International Health Regulations (IHR) Capacities³⁵ is a comprehensive tool designed to provide specific guidance and measures to strengthen countries’ emergency preparedness. It contains a list of standardized and corresponding actions that can be implemented to improve countries’ IHR capacities to develop a national action plan for health security.

For example, some strategic actions in the WHO benchmark tool were outside the scope of Nigeria’s state constitutional jurisdiction, such as vaccine purchase, which is traditionally the responsibility of the national government. This posed a challenge for external evaluators reviewing these capacities during the plenary and consensus-building session. Nonetheless, we engaged extensively with state counterparts through detailed discussions and consensus building to determine scoring for specific technical areas. This led to the development of the subnational health security benchmarking tool,³⁶ which addressed the nonalignment concerns observed while piloting the assessment tool.

In addition, we learned from the process evaluation that identifying high-level champions with relevant authority and technical expertise early in the process is critical for the successful conduct of an assessment. Granting states greater ownership in the assessment planning process, including the discretion to choose assessment dates and communicate with intended participants, fostered increase participation and commitment throughout the assessment. Overall, political will and state commitment were critical to the success of the state JEE.

Initial findings from the tool’s application have demonstrated its effectiveness in mobilizing stakeholders and enhancing multisectoral collaboration using the One Health approach, with a view to sustainability; this contrasts with the ad hoc structures established during the COVID-19 response in the pilot states. For instance, Kano State, using the tool’s recommendations, has developed a state action plan for health security,³⁷ a comprehensive multisectoral costed plan with an estimated budget of 1.232 billion Nigerian naira (about US$2,679,920) to address gaps in health security in the state. Additionally, the state legislative assembly recently passed a subnational health security bill aimed at establishing a legal, institutional framework and financing to address critical gaps identified through the tool’s deployment across the 14 technical areas.³⁸ The bill provides a pathway for Kano State to codify the IDSR and its implementation within a state legal framework, marking a significant achievement. The other 2 pilot states (Enugu and Kebbi) are in an advanced stage of drafting similar health security bills. The NCDC has adopted the use of the tool into its recently launched 5-year strategic plan.³⁹

Implications for IDSR Implementation

Since the WHO African region’s adoption of the IDSR strategy in 1998, its implementation across countries has encountered various challenges. These include inadequate financing, lack of sustainable domestic resources, insufficient training and high turnover of peripheral staff, inadequate sharing of surveillance data, weak laboratory capacities, and reduced availability of communication and transport systems, particularly at the subnational level, to support specimen transport.^13,40-42 Addressing these challenges requires substantial investment by both the national and subnational governments in infrastructure, capacity building, coordination mechanisms, and community engagement strategies.

As elaborated in the results from Nigeria’s 2017 JEE¹⁴ and 2019 midterm JEE,¹⁵ key determinants could enhance implementation of the IDSR strategy. These determinants are described in the JEE technical areas and the WHO benchmarks for IHR. Directly related to the implementation of the IDSR are policy, legislation, medical countermeasures, surveillance, laboratory functionality, human resources, and other areas that require multisectoral coordination such as linking public health and security agencies.¹⁷

Based on a review of JEEs conducted so far in Africa,²⁵ a number of countries have yet to achieve their desired capacities in these key technical areas, which focus on the national level. This could have had an impact on the level of progress made with IDSR strategy implementation.

Use of the subnational assessment tool presents an opportunity for states to articulate their challenges into plans and mobilize resources to address identified gaps. Early progress has been observed in Kano State with the development of its state action plan for health security, which addresses the gaps identified in the assessment; these gaps undoubtedly reflected the challenges observed with IDSR implementation.³⁷ Furthermore, inspired by the tool’s application, especially in evaluating legal and institutional frameworks that support epidemic preparedness and response, states are now taking steps to incorporate IDSR into their health security laws.³⁸ This approach will guarantee sustainable implementation, tracking, and funding of IDSR.

Discussion

Although the JEE requires subnational capacities, in a large country such as Nigeria, the subnational health security gaps identified in the JEE cannot necessarily be translated equally to all state settings. The states’ epidemic risk profiles differ from each other, with the states spread from the borders of the Sahara Desert in the north to the Atlantic Ocean and dense rainforests in the south. This is critically important because health security and preparedness efforts are implemented and financed at the state level. Furthermore, there is growing recognition that capacities need to be built at the lowest levels of the system (eg, health facilities, districts, communities); this was evidenced by the COVID-19 pandemic and further highlighted by findings from implementation of the 7-1-7 target in Nigeria and impetus to develop epidemic-ready primary healthcare systems.^43,44 Additionally, Nigeria is rolling out innovative health financing mechanisms such as the Basic Health Care Provision Fund. Findings from this subnational assessment, aided by our tool, will prove helpful for implementing the Basic Health Care Provision Fund by providing states data to identify critical interventions for prioritization.⁴⁵

Beyond the national level, conducting a subnational health security assessment using a bespoke tool is an innovative approach for countries with a multilayered system of governance to better understand and address weaknesses in their health security capacities and make deliberate plans to mitigate the occurrence of events of public health importance. Conducting an IHR capacities assessment using the subnational tool provides Nigeria an opportunity not only to identify strengths and weaknesses of local-level health security systems but also to support NCDC-led efforts to strengthen health security.

It is also important to recognize that health security is not the role of ministries of health alone; multisectoral coordination and collaboration across different government ministries, departments, and agencies enable effective response to public health events. To that end, deployment of the subnational health security tool will provide critical insights for engendering cross connections in areas such as the legislature; such connections are necessary for establishing sustainable and predictable financing to address critical bottlenecks that may have inhibited full implementation of the IDSR and thus facilitating fulfillment of the IHR requirements.⁴⁶

Furthermore, the output generated from the subnational tool can inform subnational entities’ resource-mobilization efforts. Before now, adequate financial resources were not made available for responding to disease threats.⁴⁷ This was often due to poor prioritization of response activities in budgetary allocations. The subnational tool can be used to create multiyear action plans and better prioritize resources despite competing priorities. In the tool, we created a standalone indicator for financing to amplify the significant role of routine and emergency financing in attaining a desirable health security status at the subnational level.⁴⁶ This view is further reinforced by recommendations by the International Working Group on Financing Preparedness, which advocates for countries to increase their domestic spending on development and specific health-related concerns, including preparedness, to maximize ownership and self-reliance.⁴⁸ Deploying this tool will support attainment of this recommendation.

Results from deploying the assessment tool will provide an objective view of preparedness and response capacities at the state level and at the national IHR focal point (NCDC). This will further guide government and partners’ health security investments and prioritization across states. The assessment will also generate state-specific data, which can be used to develop improvement plans to bridge the identified gaps in the states considering state-specific peculiarities while also serving as advocacy tools to facilitate discussions with key stakeholders.

Deploying the subnational tool can also promote accountability and transparency.^42,43 With publication of assessment results on a public platform, citizens can make informed demands and hold their respective governments accountable for services that will improve preparedness and response efforts.

The assessment tool has now been deployed in 11 states and the Federal Capital Territory in Nigeria. The NCDC’s new 5-year strategic plan (2023 to 2027) focuses on scaling up the assessment to the remaining 26 states within the next 12 months.³⁹ At the global level, there has been early adoption and integration of the revised technical areas and indicators used in the subnational assessment tool, notably within the published third edition of the JEE tool framework. The JEE 3.0 tool has incorporated indicators resembling those found in the subnational tool, such as indicators on health security governance and safer health facilities.

The limitation of the tool is that it primarily assesses states’ adherence to IHR requirements at a defined point in time rather than evaluating the effectiveness of implementation in real-world scenarios. Capacity assessments, such as the JEE, complement functional reviews (intra-action/early action/after-action reviews) and 7-1-7 metrics and should integrate with risk assessments at the planning stage, like the national and state action plans for health security.

Conclusion

In countries with a federal system of government and multilayered governance structures, ample consideration should be given to understanding the critical gaps impeding the achievement of desired health security capacities. In such settings, we recommend the conduct of a legal analysis and desk review to prioritize technical areas under subnational jurisdiction, determination of which capacities are of greatest importance to measure at the subnational level to complement existing assessment processes and frameworks, review by multiple stakeholder groups, and incorporation of the assessment tool into a more extensive process of advocacy, change management, and integration of operational planning with subnational budget lines as appropriate. The translation and implementation of assessment findings into budget planning and implementation can strengthen IDSR implementation in the broader context of the enabling environment (legislation, governance, and financing) with technical progress in IHR core capacities.

Footnotes

Acknowledgments

The authors thank Resolve to Save Lives for funding the pilot of subnational health security assessments in the selected states. Additionally, we extend our appreciation to the leadership of the NCDC for their instrumental role in fostering the engagement and technical implementation in the intervention. This analysis was conducted with funding from grants from Bloomberg Philanthropies, #startsmall, the Bill & Melinda Gates Foundation, and the Chan Zuckerberg Initiative Donor-Advised Fund at the Silicon Valley Community Foundation.

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