Towards a safer future: Learnings from a decade of public health emergencies in the South-East Asia Region

A SAFER FUTURE TOWARDS Learnings from a decade of public health emergencies in the South-East Asia Region Towards a safer future: Learnings from a decade of public health emergencies in the South-East Asia Region ISBN 978-92-9022-884-4 © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Disclaimer: The boundaries and names shown and the designations used in the maps, in this document do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Acknowledgements • This publication is a tribute to the resilience and strength of the people of the South-East Asia Region. Thanks to • Jos Vandelaer for his vision and leadership • Roderico Ofrin and Nilesh Buddh for guidance and advice on the concept of this project Eigil Sorensen, for his expert technical guidance and conceptualization of the content • Lin Aung, Anil K Bhola, Supriya Bezbaruah, Balwinder Singh Chawla, Aarti Garg, Maung Maung Htike, Mohamed Ismail, Masaya Kato, Arturo Pesigan, Kai Von Harbou, Pushpa Ranjan Wijesinghe, Gyanendra Gongal, Reuben Samuel, Victor Del Rio Vilas, and staff of the WHO Health Emergencies programme (WHE) in the South-East Asia Region for contribution to research, content and writing • Taru Bahl and Supriya Bezbaruah for writing and project management • Ambika Arora for support in photos and administrative processes • Rouge Communications for design and layout • The many dedicated WHO staff, experts deployed or working in emergency preparedness and response, whose tireless efforts have contributed to making this region a safer place during public health emergencies Learnings from a decade of public health emergencies in the South-East Asia Region A SAFER FUTURE TOWARDS © W H O /J oe S w an Contents List of abbreviations iv Glossary vi Foreword x Executive Summary xii 09 Strengthening regional emergency preparedness through international health regulation (2005) 117 01 01 Turning commitments into actions: perspectives on emergency preparedness in south-east asia 10 One health: zoonotic threats and food safety - collaboration between human and animal health authorities 133 02 19 Regional risk profile & vulnerabilities: an all-hazard approach 11 Harnessing digital technologies to sharpen public health response to COVID-19 03 33 Country preparedness for public health emergencies 12 The value of risk communication & community engagement in overall preparedness and response 45 04 Building resilient health systems 13 Addressing concerns of vulnerable populations: the rohingya crisis 6305 Role of frontline health workers in emergencies 14 Harnessing digital technologies to sharpen public health response to covid-19 06 75 Regional risk profile & vulnerabilities: an all-hazard approach 15 The value of risk communication & community engagement in overall preparedness and response 07 87 Country preparedness for public health emergencies 08 101Building resilient health systems 149 163 179 187 201 Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region iv EMTCC Emergency Medical Team Coordination Cell EPR Emergency preparedness and response ERF Emergency Response Framework EWARS Early warning, alert and response system FAO Food and Agriculture Organization FDMN Forcibly Displaced Myanmar National FETP Field Epidemiology Training Programme GBV Gender-based violence GFN Global Foodborne Infections Network GHSA Global Health Security Agenda GISRS Global Influenza Surveillance and Response System GLEAN Global Leptospirosis Environmental Action Network GPMB Global Preparedness Monitoring Board GPW General Programme of Work GSS Global Salmonella Surveillance HC Humanitarian Coordinator HCC Health Cluster Coordinator HCF health-care facility HCT Humanitarian Country Team HCW Health-care worker HDPR Hospital Disaster Preparedness and Response HEDRM Health Emergency and Disaster Risk Management HEOC health emergency operations centre HLIP High-Level Implementation Plan HPED Highly Pathogenic Emerging Disease HSI Hospital Safety Index IAR Intra-action review ICDDR,B International Centre for Diarrhoeal Disease Research, Bangladesh IDP Internally displaced person IEHK Interagency health kits IFRC International Federation of Red Cross IHR International Health Regulations ILI Influenza-like illness IMS Incident Management System IMST Incident Management Support Team AAR after action review AFRIMS Armed Forces Research Institute of Medical Sciences AG advisory group AI Artificial intelligence AMR Antimicrobial resistance APSED Asia-Pacific Strategy for Emerging Diseases ASEAN Association of Southeast Asian Nations ASHAs Accredited Social Health Activists AU African Union BEC Basic emergency care BFA Basic first aid BSL-3 Biosafety Level-3 CBD Convention on Biological Diversity CCHF Crimean–Congo haemorrhagic fever CDC Centers for Disease Control CERF Central Emergency Response Fund CFE Contingency Fund for Emergencies CHDSO Camp Health and Disease Surveillance Officer CHW Community health worker CLA Cluster Lead Agency CSO Civil society organization CTF Codex Trust Fund DAT Diphtheria Antitoxi DGDA Directorate General of Drug Administration DHIS2 District Health Information Software 2 DRC Danish Red Cross DRR disaster risk reduction DSE Disease Surveillance and Epidemiology ECHO European Commission Humanitarian Aid ECS Emergency Care System EDLPN Emerging Dangerous Pathogen Laboratory Network EDRM Emergency and Disaster Risk Management EHA Emergency and Humanitarian Action EMDT Emergency Medical Deployment Team EMT Emergency Medical Team List of abbreviations vTowards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region PHEIC Public health emergency of international concern PHEOC Provincial Health Emergency Operation Centre PIP Pandemic Influenza Preparedness PPE Personal Protective Equipment PSEA Prevention of Sexual Exploitation and Abuse PVS Performance of Veterinary Services QMSI Queen Saovabha Memorial Institute RC Resident Coordinator RCCE Risk Communications and Community Engagement REG Regulatory Capacity Building RMSRS Rumour and misinformation surveillance and response system ROAP Regional Office for Asia and the Pacific SAARC South Asian Association for Regional Cooperation SAG Strategic Advisory Group SAGE Strategic Advisory Group of Experts SAM Severe acute malnutrition SARE Stepwise approach for rabies elimination SARI Severe acute respiratory infection SEAMEO South-East Asia Ministers of Education Organization SimEx Simulation exercise SoP Standard operating procedure SPAR State Party Self-Assessment Annual Report SRRT Surveillance and Rapid Response Team STAR Strategic assessment of risk UHC universal health coverage UHC Upazila Health Complex UNHCR United Nations High Commissioner for Refugees UNISDR United Nations International Strategy for Disaster Reduction WASH Water, sanitation and hygiene WHA World Health Assembly WHE Health Emergency Programme WHO World Health Organization IMT Incident Management Team IOM International Organization for Migration IoT Internet of Things IPC Infection prevention and control ISCG Inter-Sector Coordination Group JE Japanese Encephalitis JEE Joint External Evaluation JRP Joint Response Plan JUNIMA Joint United Nations Initiative on Migration and Health in Asia LBM4 laboratory biosafety manual LQSI Laboratory Quality Stepwise Implementation M&E Monitoring and evaluation MAT Microscopic agglutination test MCK Medical camp kit MERS Middle East Respiratory Syndrome MoH Ministry of Health MoHFW Ministry of Health and Family Welfare MoHP Ministry of Health and Population MSF Médecins Sans Frontiers MTCT mother-to-child transmission NAPHS National Action Plan for Health Security NCC National Codex Committee NCDC National Centre for Disease Control NCD Non-communicable disease NFP National focal point NGO Non-governmental organization NIID National Institute of Infectious Disease NIMHANS National Institute of Mental Health and Neuroscience NIPPP National influenza pandemic preparedness plan NOC No-objection certificate OCHA Office for the Coordination of Humanitarian Affairs OSL Operations support and logistics PC Partnership contribution PCV Pneumococcal conjugate vaccines PHC Primary health care Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region vi When microorganisms such as bacteria, viruses, fungi and parasites change in ways that render medications used to cure the infections they cause ineffective (WHO). ANTIMICROBIAL RESISTANCE The set of measures taken to ensure safe handling of biohazardous materials, such as pathogens, biological contaminants, and genetically modified organisms, especially to prevent their accidental spread beyond a laboratory or research facility. BIOSAFETY A strategic and integrated approach to analyzing and managing relevant risks to human, animal and plant life and health and associated risks for the environment. It is based on recognition of critical linkages between sectors and the potential for hazards to move within and between sectors, with system-wide consequences (WHO). BIOSECURITY Group of agencies, organizations and/ or institutions working together towards common objectives to address needs in a particular sector such as health (WHO). CLUSTER IN DISASTER RESPONSE An agency/organization that formally commits to take on a leadership role within the international humanitarian community in a particular sector/area of activity, to ensure adequate response, and high standards of predictability, accountability, partnership, and to serve as provider of last resort when necessary (IASC). CLUSTER LEAD Glossary viiTowards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Use of digital technologies for health, employing routine and innovative forms of information and communications technology to address health needs. DIGITAL HEALTH Serious disruption of the functioning of a community or society at any scale due to hazardous events interacting with conditions of exposure, vulnerability and capacity, leading to one or more of the following: human, material, economic and environmental losses and impacts (UNISDR). DISASTER Situation impacting lives and well-being of a large number of people or a significant percentage of a population and requiring substantial multisectoral assistance (WHO). EMERGENCY Long-term development activities whose goals are to strengthen overall capacity and capability of a country to manage efficiently all types of emergency and bring about an orderly transition from relief through recovery and back to sustainable development (WHO). EMERGENCY PREPAREDNESS Humanitarian crisis in a country, region or society where there is total or considerable breakdown of authority resulting from internal or external conflict and which requires an international response that goes beyond the mandate or capacity of any single and/or ongoing UN country programme (IASC). COMPLEX EMERGENCY An acute public health event or emergency that requires an operational response by WHO. There are three WHO grades for emergencies, signifying the level of operational response by the organization: Grade 1 (limited response), Grade 2 (moderate response), and Grade 3 (major/maximal response). If a graded emergency persists for more than six months, it may transition to a protracted emergency (WHO Emergency Response Framework 2017). GRADED EMERGENCY PROTRACTED EMERGENCY Actions taken directly before, during or immediately after a disaster or emergency in order to save lives, reduce health impacts, ensure public safety and meet the basic substance needs of the people affected (UNISDR). EMERGENCY RESPONSE An environment in which a significant proportion of the population is acutely vulnerable to death, disease and disruption of livelihoods over a prolonged period of time. Governance in these settings is often weak, with limited state capacity to respond to, and mitigate, the threats to the population, or provide adequate levels of protection (WHO Emergency Response Framework 2017). INTER- NATIONAL RESPONSE Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region viii Emergency preparedness requires attention not just to specific types of hazards but also to actions that increase preparedness for all risks. In view of these common components, WHO as well as other leaders in crisis management advocate the "All"- hazards approach as the recommended mechanism for emergency preparedness. “ALL” HAZARDS APPROACH The standardized structure and approach that WHO has adopted to manage its response to public health events and emergencies, and to ensure that the organization follows best practices in emergency management. WHO has adapted the incident management system to consist of six critical functions: leadership, partner coordination, information and planning, health operations and technical expertise, operations support and logistics, and finance and administration (WHO Emergency Response Framework 2017). INCIDENT MANAGEMENT SYSTEM The in-country team responsible for managing and implementing the WHO response to an emergency. It is structured around the six critical incident management system functions and their associated sub-functions. The size and composition of the team is flexible and can vary according to the context (WHO Emergency Response Framework 2017). INCIDENT MANAGEMENT TEAM The leader of the incident management team, who is responsible for strategic leadership and day-to-day management and oversight of WHO’s response to an emergency. The incident manager serves as the overall lead of the incident management team and delegates authority to other critical functions as they are established. S/he works with the health authorities and partners to agree on strategic priorities and objectives for the health response, fully consistent with humanitarian principles [WHO Emergency Response Framework 2017]. INCIDENT MANAGER An overabundance of information, both online and offline. It includes deliberate attempts to disseminate wrong information to undermine the public health response and advance alternative agendas of groups or individuals (WHO). INFODEMIC An international legal instrument that is binding on 196 countries across the globe, including all the Member States of WHO to prevent, 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. INTERNATIONAL HEALTH REGULATIONS (2005) A person who migrates from one country to another with a view to being employed (ILO). Can also be used to describe someone who migrates within a country, possibly their own, in order to pursue work such as seasonal work. MIGRANT WORKER A possible threat of source of exposure to injury, harm or loss, for example, conflict and natural phenomena. Hazards include biological, environmental, geological, hydrometeorological and technological processes and phenomena (Inter-Agency Contingency Planning Guidelines for Humanitarian Assistance 2001). HAZARD ixTowards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Any event that may have negative consequences on human health. The term includes events that have not yet led to disease in humans but have the potential to cause disease through exposure to infected or contaminated food, water, animals, manufactured products or environments (WHO Emergency Response Framework 2017). PUBLIC HEALTH EVENT Someone who is unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion (1951 Refugee Convention). People who have fled war, violence, conflict or persecution and have crossed an international border to find safety in another country (UNHCR). REFUGEE An evaluation of the probability of the occurrence and magnitude of the consequences of any hazard, that is, how likely is a hazard and what consequences will it have? (Inter- Agency Contingency Planning Guidelines for Humanitarian Assistance 2001) RISK Systematic analysis and management of health risks, posed by emergencies and disasters, through a combination of hazard and vulnerability reduction to prevent and mitigate risks; preparedness; response; and recovery measures (WHO). EMERGENCY RISK MANAGEMENT FOR HEALTH Exchange of real-time information, advice and opinion between experts and people facing threats to their health, economic and/or social well-being. The ultimate purpose of risk communication is to enable people at risk to take informed decisions to protect themselves and their loved ones (WHO). RISK COMMUNICATION Infectious diseases that have jumped from non-human animals to humans (WHO). ZOONOSES Delivery of health-care services, where patients and providers are separated by distance. It uses information and communications technology for exchange of information for diagnosis and treatment of disease and injuries, research and evaluation, and for continuing education of health professionals. TELEHEALTH Resilience can be informed by a collection of metrics such as redundancy, robustness or reliability, and time to restoration, including time to respond to perturbation as in the case of COVID-19 when there were increased demands on the health system, and time to restore if failure occurs. RESILIENCE Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region x The WHO South-East Asia Region is among the world’s most at-risk regions from a range of public health hazards that can trigger acute public health events. Since 2014 strengthening emergency risk management has been a Flagship Priority in the Region, enhanced by the establishment in 2016 of the WHO Health Emergency Programme. In 2019 the Region adopted the Delhi Declaration on Emergency Preparedness, with a focus on mobilizing additional investments in protecting people and systems, and in developing national action plans for health security. Member States have in recent years made significant progress in advancing compliance with the International Health Regulations (IHR 2005), with State Party Assessment Reports showing consistent yearly gains, including an average 7% increase in IHR core capacities between 2018 and 2020. The emergence and spread of COVID-19 has shown that no country in the Region – and few across the world – were fully prepared to handle a large-scale and protracted epidemic caused by a novel virus. The pandemic has underscored the critical need for countries in the Region and across the world to achieve full IHR compliance, and to enhance health system resilience to end this pandemic and prepare for and prevent the next outbreak. In this context, this book highlights country experiences from emergencies and disasters over the last decade, including the steps taken to strengthen health security and emergency preparedness and response capacities. It provides critical insights into the complex technical, administrative and humanitarian aspects of preparing for, preventing and responding to public health crises and documenting a series of WHO- recommended best practices that countries can tailor to their needs. Foreword xiTowards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region The intra-action and after-action reviews and assessments mentioned in this book can help countries identify priority actions to strengthen national and sub-national core capacities and enable them to fully implement national health security plans. It is imperative that all countries in the Region build health system resilience so that they can adequately respond to unexpected events, while also maintaining essential health services – one of the Region’s key priorities throughout the pandemic response. Health system resilience is an essential component of health security, underscoring the critical link between health security and the achievement of universal health coverage, as outlined in WHO’s Thirteenth General Programme of Work1. As the following pages highlight, communities have a central role to play in enhancing emergency preparedness and response capacities, and must be empowered to act, including through the development and delivery of high-quality risk communication. I trust that this book will be of great use to health officials, professionals and teaching institutions in all countries of the Region as they continue to strengthen capacities to end this pandemic, prepare for and prevent the next, and achieve full IHR compliance. WHO will continue to support all countries in the Region to achieve these outcomes and attain the healthier, more health-secure future to which we are committed. Dr Poonam Khetrapal Singh Regional Director, WHO South-East Asia 1 The Thirteenth General Programme of Work (GPW 13) defines WHO’s strategy for the five-year period, 2019–2023. It focuses on triple billion targets to achieve measurable impacts on people’s health at the country level. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region xii T he first two decades of the 21st century have shown that countries in WHO’s South-East Asia Region are exposed to diverse types of hazards which, if not managed well, may lead to disasters and public health emergencies, including outbreaks and emerging diseases. The unprecedented scale and intensity of the Indian Ocean Tsunami 2004 led countries to review their capacities to manage similar large-scale events. Subsequently, the SARS outbreak in 2003, avian influenza (H5N1) outbreak in 2005, H1N1 Influenza pandemic in 2009, Ebola virus disease outbreak in West Africa in 2014–16 and the ongoing COVID-19 pandemic have time and again drawn attention to vulnerabilities and risks which each of the 11 countries in the Region face. After the experience of the 2004 Tsunami and the introduction of the International Health Regulations (2005) that came into effect from 2007, WHO made significant investments to strengthen its capacity to support national emergency preparedness and response programmes in the Region. The WHO South-East Asia Region Benchmarks for Emergency Preparedness and Response Framework with its standards and indicators have been used to assess existing capacities of countries in emergency risk management with focus on public health. The Region’s capacity was further enhanced in 2014 when Emergency Risk Management was established as a regional flagship programme. The setting up of the South-East Asia Regional Health Emergency Fund (SEARHEF) in 2008 and its further expansion to include a “preparedness stream” in 2016 was an important milestone. The endorsement of the Five-year regional EXECUTIVE SUMMARY A well-functioning health information system at national and sub-national level supporting linkages across scales is a critical part of resilient health systems. xiiiTowards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region The SARS outbreak in 2003 Indian Ocean Tsunami 2004 H1N1 influenza pandemic in 2009 COVID-19 in 2020-21 Avian influenza (H5N1) outbreak in 2005 Ebola virus disease outbreak in West Africa in 2014–16 strategic plan to strengthen public health preparedness and response: 2019–2023 by Member States was another step forward. Further, the Delhi Declaration on Emergency Preparedness, adopted in September 2019 at the 72nd Regional Committee Meeting, asked Member States to invest resources in protection of people and systems, and specifically for emergency risk management, to develop national action plans for health security. For countries to have an understanding of risks at subnational and national level, a first-ever risk assessment and mapping exercise was undertaken by WHO’s Regional Office for South-East Asia in 2017. Risks for all countries of the Region were quantified for disasters and diseases providing a comprehensive understanding of their vulnerabilities. Building resilient health systems with capacity to respond to public health emergencies The current COVID-19 pandemic is a reminder of how health systems can become overburdened by public health emergencies. Resilient and robust health systems, oriented towards primary health-care, ensure not only the capacity to respond effectively to unexpected events, but also to maintain delivery of essential health services while responding to crisis. Effective and coordinated strengthening of primary health-care-oriented health systems contribute to improved health security for better prevention, detection and response to public health events and threats. A resilient health system is an essential element of health security and highlights the close link between health security and health system as outlined in WHO’s General Programme of Work 13 (GPW). Disclaimer: The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Reliable and timely results from laboratory investigations are critical elements for decision-making in clinical care, epidemic response is vital for the surveillance, prevention and control of diseases of public health importance. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region xiv Resilient health systems have inbuilt surge capacities to manage small- and large- scale emergencies. The effectiveness of the everyday handling of emergencies from onsite response to hospital care is a major determinant of local health sector capacity to cope with major public health emergencies. A well-prepared and trained health workforce is a fundamental requirement for delivering quality health-care for both routine service delivery and emergency response. The important and heroic role of frontline health workers has been demonstrated during the pandemic. While there has been important progress in health workforce availability in the region, as evidenced by the Mid-term Review of the SEAR Decade for Health Workforce Strengthening, the current density of doctors, nurses and midwives across the region remains by and large, below global standards. There is also a longstanding challenge with respect to the distribution and quality of health workers. Similarly, the designated number of public health officers and trained field epidemiologists do not achieve the target as required by WHO. The role of community and traditional health workers also deserves emphasis in the context of building resilient health systems that are close to the community. National standards for assessment of the safety of critical health infrastructure, and their systematic application, is a high priority. After learning lessons from the Tsunami of 2004, WHO, through the global Safe Hospitals programme, produced comprehensive policy guidance on, and practical tools for, conducting critical health infrastructure assessments. Since the Nepal earthquake of 2015, the SEA Region has offered technical support to countries in safety assessment of key health infrastructure and is providing support to Ministries of Health to take corrective measures. These standards are yet to be adopted as mandatory in designing and constructing new health infrastructure in many countries. A well-functioning health information system at national and sub-national level supporting linkages across scales is a critical part of resilient health systems. © W H O /B an gl ad es h © W H O /B an gl ad es h © W H O © W H O xvTowards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Reliable and timely results from laboratory investigations are critical elements for decision-making in clinical care, epidemic response is vital for the surveillance, prevention and control of diseases of public health importance. Public health laboratory services are an indispensable part of emergency response capacity. Reliable and timely results from laboratory investigations are critical elements for decision-making in clinical care. Also, epidemic response is vital for the surveillance, prevention and control of diseases of public health importance. Considerable effort has gone into improving health laboratory services with a focus on specific communicable diseases such as tuberculosis and influenza, but fewer efforts have been made to improve more generic capacities of public health laboratories. Laboratory services need to be considered as an integrated public health laboratory system, not as standalone with only parts of the system strengthened to support specific disease control initiatives. National reference laboratories for essential diagnostic areas like virology, bacteriology and molecular techniques are crucial, but they must be coupled with routine public health laboratory capacity at subnational level. Improvements in digital technology provide a platform for integrated laboratory information management systems for quick turnaround of results. A trend currently observed in the Region is the decentralization of health systems, often as part of broader public and administrative reforms. The COVID-19 pandemic has illustrated the importance of functioning subnational health services and, in particular, the importance of investments in primary health care, with strong links to secondary and tertiatry levels of care. The capacity to detect outbreaks means not only having laboratory capacity at district level, but also the authority and means to protect health workers, quarantine for exposed and suspect cases, isolate and treat clinical cases and undertake rapid and exhaustive contact tracing. Quick action on local epidemiological data by local authorities has been a key success factor in managing COVID-19. However, this depends on the availability of well-trained public health managers, © W H O /A hm er K ha n Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region xvi and technical staff and epidemiologists at subnational level working closely with public and private hospitals, grassroots and community organizations and local authorities. A well-functioning health information system at national and subnational level supporting linkages across scales is a critical part of resilient health systems. Strengthening emergency preparedness through International Health Regulation (2005) Many initiatives have been implemented in the SEA Region to strengthen the Member States’ IHR capacities. Following IHR assessments, most countries developed and implemented their National Action Plans for Health Security (NAPHS). These are aligned with national health sector plans linking activities using the One Health approach2 and embracing broader health system strengthening with full government and society involvement. The WHO SEA Regional Knowledge Network of IHR National Focal Points (NFP) established in 2019. The online knowledge network has served as a platform for sharing information, best practices and conducting of online capacity building. More stability in terms of retaining with IHR NFP is needed so that their technical capacities could be built and expertise strengthened to ensure data consistency in IHR State Party Self-Assessment Annual Report (SPAR) reporting. Even prior to the pandemic, countries in the Region were focusing on strengthening tools and processes for assessing, monitoring and reporting on core capacities of IHR (2005). These included undertaking functional assessments to allow more accurate situation analysis and dynamic adaptation of management strategy at national and subnational levels. Future direction for assessment of IHR core capacities should take place in parallel with health system capacity assessment on universal health coverage (UHC)3 for more accurate analysis of capacities at national and subnational levels. A limited number of countries are however still reluctant to conduct the voluntary Joint External Evaluation (JEE) process. A well-functioning health information system at national and sub-national level supporting linkages across scales is a critical part of resilient health systems. © W H O /M al di ve s 2 ‘One Health’ is an approach to designing and implementing programmes, policies, legislation and research in which multiple sectors communicate/work together to achieve better public health outcomes. Areas in which a One Health approach is relevant include food safety, control of zoonoses and combatting of antibiotic resistance. 3 UHC means all individuals and communities receive health services they need without financial hardship. It includes essential, quality health services, from health promotion to prevention, treatment, rehabilitation and palliative care across the life course. Achieving UHC is one of the targets adopted as part of the SDGs in 2015 and countries reaffirmed this commitment at the UN General Assembly High Level Meeting on UHC in 2019. xviiTowards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Zoonotic threats need effective collaboration between human and animal health authorities Outbreaks of new and emerging zoonoses at the human-animal-environment interface demand closer cross-sectoral coordination and technical collaboration between national authorities, WHO, Food and Agriculture Organization (FAO) and World Organization for Animal Health (OIE). This should include establishing of a One Health Secretariat at the national level for surveillance of priority zoonoses and response to zoonotic events using the tripartite (WHO-FAO-OIE) operational tools. WHO’s Regional Office for South-East Asia is enhancing its technical support on zoonoses and veterinary public health by making better use of WHO Collaborating Centres that are mandated to provide technical advice, build capacities and provide referral services. They also engage with academic institutions in the Region through their teaching and research programmes on One Health. World Health Organization (WHO) World Organization for Animal Health (OIE) Food and Agriculture Organization (FAO) Between 2015 and 2019, the Regional Office worked with Member States to establish a functional National Codex Committee and to build capacities to conduct assessments of foodborne disease surveillance and response services. Priority actions have been identified in eight countries where foodborne disease surveillance system has been established, capacity building for outbreak investigation undertaken and food safety emergency response planning completed. Outbreaks of new and emerging zoonoses at the human- animal environment interface demand closer cross-sectoral coordination and technical collaboration between national authorities, WHO, Food and Agriculture Organization and World Organization for Animal Health. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region xviii The first WHO guideline on digital health interventions for health-system strengthening was published in 2019. The COVID-19 pandemic provided unprecedented opportunity for digital solutions, but with mixed results. While on one hand, successful expansion of telehealth, telemedicine and other digital clinical applications was seen, on the other hand, few less successful digital public health measures related to contact tracing and for monitoring home/ self-quarantine were also observed. A systems-level approach will be needed to inform how digital strategies can be further incorporated into not just COVID-19- control strategies but other infectious diseases too. Evidence is being gathered to better understand the barriers to implementation, including legal, ethical and privacy issues in addition to governance, organizational and workforce barriers. A range of digital data sources are being used to enhance and interpret key epidemiological data gathered by public-health authorities for COVID-19. Data- aggregation systems, including a programme for monitoring emerging diseases (ProMED-mail), Global Public Health Intelligence Network (GPHIN), HealthMap and Epidemic Intelligence from Open Sources (EIOS), which use natural language processing and machine learning to process and filter online data, have been developed to provide additional epidemiological insights. They are now being increasingly integrated into the formal surveillance landscape with good results. Analysis and use of data will depend on digital infrastructure and readiness of public-health systems. Countries and their health systems must be legally empowered to introduce digital health armamentarium to combat diseases and improve health. It is necessary to generate evidence of effectiveness of digital health interventions and promote appropriate integration and use of technologies. Digital technologies in the public health emergency response Countries and their health systems must be legally empowered to introduce digital health armamentarium to combat diseases and improve health. Tele health, Contact tracing Monitoring Home quarantine xixTowards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Risk communication and working with communities Risk communication is the dissemination of information to the public about health risks and events. It also entails providing advice on how to change behaviours in order to prevent and mitigate risks. In the last decade or so, the entire approach towards how risk communication is formulated and delivered has evolved dramatically. It has been driven by the introduction of new communication platforms and evidence collected by social sciences on how people communicate and process both information and misinformation acquired through digital platforms. The fundamental source of transformation has been technological. Increased connectivity and internet penetration, proliferation of smart phones, and emerging popularity of social media apps, has fundamentally changed how information is sourced, analyzed and communicated. Rumours and misinformation now spread in seconds, making the role of credible agencies critical in order to avert hysteria, panic and misinformed decision making. The challenge of infodemics4 will only increase, and it is essential to stay ahead of the curve by investing in technology and systems to manage situations through digital means and traditional community engagement. Communities are often the first responders to any emergency, even before any government officials or agency can reach them. It is not only about the engagement per se, but more importantly, how to engage that needs to be reviewed. Strengthening of health volunteer programmes and use of community health workers, integrated into the primary health-care system, has emerged as an important investment with immense potential during the COVID-19 pandemic. Grassroots non-governmental organizations (NGO) and civil society organizations (CSO) working in the area of health have effectively bridged community concerns with government services and advisories. Greater investment in and sensitization of public health staff and CHWs on culturally sensitive ways to communicate with local populations and win their trust will go a long way in strengthening community engagement as required to ensure health system resilience. Communities are often the first responders to any emergency, even before any government officials can reach them. 4 An excessive amount of information about a problem that is typically unreliable, spreads rapidly, and makes a solution more difficult to achieve by virtue of its rapid spread via multiple routes. © W H O In di a/ G ho om ar M ah ila S am iti Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region xx Migrant workers – a vulnerable occupational group linked to public health risks The COVID-19 pandemic has drawn attention to migrant workers as a vulnerable occupational group. The public health risks related to their congested working and living conditions which are largely bereft of adequate sanitation and hygiene has been amply demonstrated. The ‘new normal’ must include minimum standards in the working environment and living conditions for both temporary and migrant workers, besides defining their minimum healthcare rights and protection during a sudden emergency. Countries need to manage safe repatriation of refugees and migrants at points of entry (PoE) during a public health crisis like the pandemic. There is also a call for greater cross-border collaboration to control population movements during disease outbreaks. Providing temporary permission to stay and work in the host country during the emergency, including for undocumented migrants serves as a useful approach. The ultimate aim being universal and equitable access to health services within the scope of UHC for migrants, regardless of age, gender or legal status. Education of the public through media and other communication channels will have to be strengthened to limit stigma and discrimination. The ultimate aim being universal and equitable access to health services within the scope of UHC for migrants, regardless of age, gender or legal status. © W H O /M al di ve s xxiTowards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region The new WHO health emergencies programme The creation of the WHO Health Emergencies Programme (WHE) in 2016 and adoption of the Incident Management System (IMS) as the main organizational approach to managing response to emergencies, is regarded as a major reform. The aim has been to reinvigorate WHO as an operational organization that leads health emergency management while maintaining its technical and normative functions. WHE has a new organizational hierarchy (headquarters, regional and country offices) with a clear structure and process, while the core functions for building country preparedness include emergency preparedness and emergency response. The Emergency Response Framework (ERF) provides WHO staff with essential guidance on how the Organization manages the assessment, grading of and response to public health events and emergencies with health consequences, in support of Member States and affected communities. The ERF adopts an all- hazards approach and is applicable in all public health events and emergencies. WHE in SEARO has strengthened the technical and operational capacity in both emergency preparedness and emergency response. Operations Support and Logistics (OSL) provides a full range of logistics and operations services for emergency preparedness and response readiness and post-emergency response surge and recovery activities. While the WHO Contingency Fund for Emergencies (CFE) was developed to allow early initiation of response operations, it has not yet solved the systemic problem of lack of predictable and sustainable funding for WHE at regional and country levels. The Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme has repeatedly recommended that an increased proportion of WHO core flexible funding be allocated to the WHE Programme. WHE in SEARO has strengthened the technical and operational capacity in both emergency preparedness and emergency response. © W H O /M al di ve s Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region xxii Responding to the Rohingya crisis The Rohingya crisis was the first large-scale emergency in the Region after the launch of the new WHE. It has evolved into a complex emergency with strong geopolitical and humanitarian dimensions. As a Grade 3 emergency5, a major WHO response involving the three levels of Organization was required. The incident grading system and the IMS clarified the roles across cadres. The establishment of the WHO suboffice in Cox`s Bazar, Bangladesh in 2019 was a significant milestone that provided continuity to field operations and a sense of stability that was, in line with a protracted emergency. Recruitment and deployment of all staff required in a large-scale emergency operation is very demanding on the Organization. The WHO ERF emphasizes that at the onset of all emergencies, WHO must assign and deploy adequate personnel and funds to the respective country office. As Cluster Lead Agency for health, WHO must provide Health Cluster Coordinators (HCC) who must be on the ground in the initial stage for a minimum 3−6 month period. WHE needs to train and have a pool of potential HCCs who can be deployed on short notice, while simultaneously drawing on partners such as the Global Outbreak and Response Network GOARN and Standby Partners for staff deployment. The need for initial and predictable funding for a Grade 3 Emergency is critical. Lack of funds coupled with risk aversion from relevant stakeholders can lead to delays in taking important decisions, in particular for senior field appointments and recruitments. The ERF emphasizes the WHO policy of “no regrets” so there is no blame attributed to individuals or organizations in the AARs in case there has been any over-response to the situation or emergency. The establishment of the WHO suboffice in Cox`s Bazar, Bangladesh in 2019 was a significant milestone that provided continuity to field operations and a sense of stability that was, in line with a protracted emergency. © W H O /B an gl ad es h 5 The grading (Grade 1, 2 or 3) assigned to an acute emergency indicates the level of operational response required by WHO for that particular emergency. Grade 3 requires a major/maximal WHO response. xxiiiTowards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Expanded partnerships Although extensive networking and collaborative mechanisms already exist on emergency preparedness for disease outbreak and response in the Region, more can be done to tap into the vast technical resources of Member States. The GOARN within the WHO SEA Region comprises fewer than 20 partners and less than 10% of the global number of GOARN members. Efforts are now underway to increase the number of GOARN partners in SEA. The WHE Programme should make more robust use of WHO collaborating centres, expert networks and public health institutes. These bodies can support WHO in generating technical recommendations, validated by WHO, supplement WHO capacity in a fast-moving crisis, and contribute research to better inform decision making in health emergency and disaster risk management. Engagement with academic institutions, professional societies, donors and civil societies at country and regional level will inform implementation and wider replication of WHO recommended best practices in public health emergencies. Significant progress has been made in emergency preparedness and health system readiness to handle public health emergencies in the Region in the last 10 years. The WHO Regional Office for SEA has over the last decade prioritized emergency risk management and given it a further boost through the establishment of the WHE in 2016. The ongoing Member States’ political commitment has been duly illustrated by the Delhi Declaration on Emergency Preparedness at the Regional Committee Meeting in 2019. Countries are now evaluating their COVID-19 pandemic response which has exposed several concerns related to preparedness and capacity of their health-care systems. A well-trained health work force, available at the primary health-care level, that includes civil and community stakeholders who have been trained on emergency procedures through simulation exercises and/or international deployments will serve to improve the delivery of the health system in crises. The limitations in the international instruments such as IHR (2005) for enhancing country capabilities have been demonstrated during the pandemic, and lessons learned are now being generated at country, regional and global level. The resolution from the Seventy-Fourth World Health Assembly mandates establishing of a Working Group on Strengthening WHO Preparedness and Response to Health Emergencies. This group will consider the findings and recommendations of the Independent Panel for Pandemic Preparedness and Response while the IHR Review Committee and the Independent Oversight and Advisory Committee for the WHE Programme, will give Member States a chance to shape global and regional policies and strategies to enable them respond to future public health emergencies. This initiative must be matched by additional investment by Member States towards the protection of people and systems, leading to enhacement of emergency risk management practices and national action plans (NAP) for health security. Engagement with academic institutions, professional societies, donors and civil societies at country and regional level will inform implementation and wider replication of WHO recommended best practices in public health emergencies. CONCLUSION

1 C H A P T E R Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 2 © W H O /B an gl ad es h 3Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region TURNING COMMITMENTS INTO ACTIONS Strategic interventions to strengthen capacities of countries in the WHO SEA Region for emergency preparedness and response began in 2005 before accelerating in 2014 when emergency risk management was identified as a regional flagship priority programme, based on the approach of ''sustain, accelerate and innovate6.'' Despite several commitments and progress on risk management, existing capacities to respond to health emergencies have remained inadequate in the face of multiple hazards. It is now essential to turn these commitments into actions to strengthen emergency preparedness in countries of the region. PERSPECTIVES ON EMERGENCY PREPAREDNESS IN SOUTH-EAST ASIA 6 As Member Countries pursue Flagship Priorities, the triple billion targets laid out in WHO’s 13th GPW and 2030 Sustainable Development Agenda, the imperatives are summarized by the maxim: ‘Sustain. Accelerate. Innovate’, an approach advocated by the Regional Director to fortify and fast-track public health goals Region-wide. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 4 T he WHO SEA Region is vulnerable to a wide range of natural hazards and human-induced disasters. It also has a high burden of outbreaks of common diseases and emerging and re-emerging diseases, including zoonoses. People in the Region are frequently exposed to seasonal floods, landslides, tsunamis, droughts, earthquakes, volcanic eruptions and extreme weather conditions. As noted in the World Disasters Report 2018, during 2008– 2017, about 79.8% people affected by disasters globally lived in Asia and 45.4% estimated damages resulted from disasters in Asia. Pathogens associated with recent outbreaks in countries of the region include avian influenza A(H5N1) and A(H9N2), influenza A(H1N1) pdm09, Zika virus, Middle East respiratory syndrome coronavirus (MERS-CoV), Nipah virus and Crimean Congo haemorrhagic fever (CCHF). Hazards, outbreaks and resultant health emergencies are frequent (Table 1), which clearly illustrates the high degree of vulnerability and exposure of people to prevailing risks and hazards. Hardly a year passes without an emergency in the region. Underpinning this occurrence, drivers of risk are growing rapidly in SEA. Unplanned urbanization, inequitable and risk naive development planning, close human–animal and wildlife habitations, variations in climatic conditions and newly emerging environmental health emergencies, such as air pollution are wake-up calls, © W H O /N ep al 5Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region indicating that urgent corrective measures are required to restore the ecosystem and its impact on public health. Emergency preparedness is a continuous process in which risk and vulnerability assessments, planning and implementation, funding, partnerships and political commitment at all levels must be sustained. It relies on all stakeholders working together effectively to plan, invest in, and implement priority actions. It bridges gaps between health systems strengthening, disaster risk reduction (DRR) and operational readiness to respond to emergencies. Overview of emergency preparedness in the region The Indian Ocean tsunami in 2004 alerted the whole world, and countries in South-East Asia in particular, to the need to reassess approaches to planning, designing and delivering health-care services and public health systems. It was recognized that the prevailing risks, hazards and vulnerabilities of people and systems could no longer be considered in isolation and only in the aftermath of a disaster but instead needed to be addressed and integrated into health systems and services. Since then, significant work has been done to strengthen emergency preparedness in the region (Fig 1). Emergency preparedness is defined as the “capability of the public health and health-care systems, communities, and individuals, to prevent, protect against, quickly respond to, and recover from health emergencies, particularly those whose scale, timing, or unpredictability threatens to overwhelm routine capabilities. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 6 Indian Ocean Tsunami (2004) Delhi Declaration on Emergency Preparedness endorsed (2019) z Benchmarks, standards and indicators for emergency preparedness and response published (2007) z South-East Asia Regional Health Emergency Fund established (2007) z Emergency risk management recognized as a regional flagship priority programme (2014) FIGURE 1: Key strategic interventions for emergency preparedness in WHO SEA Region, 2004–2021 z Preparedness stream of South-East Asia Regional Health Emergency Fund launched (2016) z Network of health emergency operations centres strengthened (2016–2018) z Malé Declaration adopted and Framework for action in building health systems resilience to climate change in SEA Region, 2017–2022 published (2017) z Roots for resilience: a health emergency regional risk profile of SEA Region published (2017) z Regional framework on operational partnerships for emergency response (SEA Region) published (2017) z Third Asia Pacific strategy for emerging diseases and public health emergencies (APSED III) published (2017) z WHO Regional Committee for SEA resolution on strengthening emergency medical teams (2018) z Guideline on integration of care of people with noncommunicable diseases into emergency response and preparedness published (2018) z As of 2019, all 11 countries had completed State Party annual reporting, eight had completed joint evaluation exercises, two had conducted simulation exercises, five had carried out AAR reviews and seven had drawn up national action plans for health security z Five-year regional strategic plan to strengthen public health preparedness and response for 2019–2023 published z Risk communication strategy for public health emergencies in the WHO SEA Region: 2019–2023 published (2019) z SEA Regional Knowledge Network of International Health Regulations National Focal Points established (2019) WHO Health Emergencies Programme launched (2016) 7Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region The WHO Regional Office for SEA began its efforts to develop comprehensive preparedness plans for each country of the region in 2006, focusing first on public health workforce development. Guidance on benchmarks, standards and indicators for emergency preparedness and response were produced in 2007 to assist countries in assessing their capacities to respond to health emergencies. A key mile stone was the establishment of the South-East Asia Regional Health Emergency Fund through a Regional Committee resolution SEA/ RC/60/R7 in 2007. The fund became effective in January 2008 and is designed to provide immediate financial support for the first three months in the aftermath of an emergency in countries of the region. (Read more in Chapter 3). In 2011, the Regional Office decided to focus on capacity- building and training; addressing water and sanitation and nutrition in emergencies; vulnerability assessments; and available technologies. This work synergized efforts on risk identification, mapping of health risks and multi-hazards, use of information technology and innovations in risk mitigation. The focused approach accelerated capacity-building in the health sector and related sectors for strengthening preparedness for and response to acute events. Sound risk management is essential to uphold development and implementation of local, national, regional and global strategies in the health and other sectors, including the Sustainable Development Goals, the Sendai Framework for Disaster Risk Reduction 2015–2030, the International Health Regulations 2005 (IHR) and the Paris Agreement, 2015 on climate change. The lack of preparedness of health systems in low- and middle-income countries revealed in 2014–2016 during the Ebola outbreaks in Guinea, Liberia, Nigeria and Sierra Leone, led to structural and operational reform in WHO’s emergency work. Lessons were learnt from these events, and emergency risk management was identified as one of the flagship priority programmes of the WHO SEA Region. Furhter, these programmes were established in 2014 to sustain, accelerate and innovate approaches to regional priority areas.(12) Sound risk management is essential to uphold development and implementation of local, national, regional and global strategies in the health and other sectors. © W H O / B hu ta n Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 8 Public health emergency Member state(s) affected Reported morbidity and/ or other effects Reported mortality 2011 Floods Thailand 13.6 million affected 815 deaths 2013 North India floods India, Nepal 300 000 affected, mainly in Uttarakhand, India >1000 deaths 2015 Earthquake (Richter scale 7.8) Nepal 22 303 injured; 41 199; hospitalized; 462 health facilities completely damaged, 765 partially damaged 9000 deaths Influenza A(H1N1)pdm09 outbreak India 33000 cases >2000 deaths Floods India (Chennai) 1.8 million people affected >500 deaths Floods Myanmar 1 million people affected 103 deaths 2016 Floods and landslides Sri Lanka 525 00 people affected >100 deaths Typhoon Lionrock and floods Democratic People’s Republic of Korea 100 000 made homeless 138 deaths Cyclone Roanu Bangladesh, Sri Lanka 300 000 people affected 26 deaths in Bangladesh, 204 deaths in Sri Lanka Mount Sinabung volcanic eruption Indonesia 28 536 people internally displaced 20 deaths Aceh earthquake (Richter scale 6.5) Indonesia 1000 injured 100 deaths Zika virus outbreak Bangladesh, India, Indonesia, Maldives, Thailand Number of cases: Bangladesh (1), India (4), Indonesia (1), Maldives (1), Thailand (> 360 plus 2 of microcephaly) None 2017 Dengue outbreak Sri Lanka > 185 000 cases 250 deaths Cyclone Mora Bangladesh 3.3 million people affected; 260 000 people internally displaced; 17 000 houses damaged 6 deaths Influenza A(H1N1)pdm09 outbreak Maldives 277 laboratory-confirmed cases 6 deaths Influenza A(H1N1)pdm09 outbreak Myanmar 1198 cases of severe acute respiratory infection and 401 laboratory-confirmed influenza A(H1N1)pdm09 cases 60 deaths Floods and landslides Sri Lanka 683 821 people affected; 15 897 houses damaged 224 deaths Drought Democratic People’s Republic of Korea 18 million people with food insecurity; 200 000 children with acute malnutrition 400 deaths Rohingya crisis; ongoing protracted Grade 2 emergency (as of March 2020) Bangladesh, Myanmar Approximately 1 million Rohingya people displaced to Bangladesh; public health risk of outbreaks of cholera, measles, diphtheria, tuberculosis, malnutrition; many cases of gender-based and sexual violence 273 deaths (including 105 children under 5 years of age) in the first 4 months of the crisis (August– December 2017) Table 1: Major health emergencies in the WHO SEA Region, 2011–2021 hea th emerg ncies i the South-East Asi Region 9Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Public health emergency Member state(s) affected Reported morbidity and/ or other effects Reported mortality 2018 Nipah virus outbreak India (Kerala) 19 cases, 18 of which were laboratory confirmed 17 deaths Lombok earthquake Indonesia 3 512 689 people affected; 417 529 people internally displaced 463 deaths Sulawesi earthquake and tsunami Indonesia > 200 000 people affected; > 10 600 people injured; > 4300 deaths 2019 Cyclone Fani Bangladesh, India (Odisha) > 1.2 million people evacuated in Bangladesh; 1.2 million people evacuated in Odisha, India 17 deaths in Bangladesh, 64 deaths in Odisha, India Vaccine-derived poliovirus type 1 outbreak Indonesia 1 case (January–June 2019) None Avian influenza A(H5N1) in humans Nepal 1 case (March); first human infection with avian influenza A(H5N1) in the WHO SEA Region since September 2017; first-ever case in Nepal 1 death Vaccine-derived poliovirus type 1 outbreak Myanmar 4 cases (June–July 2019) None Floods and landslides Thailand 418 000 people affected; 23 000 people evacuated; 4000 houses damaged (at 19 September 2019) 33 deaths Floods India (Assam, Bihar and Kerala) Assam: > 2.6 million people affected; Bihar: > 1.45 million people affected; Kerala: > 100 000 people affected in 13 districts 11 deaths in Assam, 29 deaths in Bihar, 175 deaths in Kerala Typhoon Lingling Democratic People’s Republic of Korea 5.3 million people affected; 460 houses and 15 public buildings damaged (2 September 2019) 5 deaths Forest fires Indonesia (Kalimantan and Sumatra) > 400 schools closed; 885 026 cases of severe respiratory illnesses (September 2019) None Dengue outbreak Bangladesh 100000 cases (July–December 2019) 93 deaths 2020 Diptheria outbreak Myanmara (Shan East province) 204 suspected cases of diphteria 10 deaths Cyclone Amphan India, Bangladesh, Sri Lanka, Bhutan Around 1.2 million people from West Bengal and Odisha in India and 2 million in Bangladesh evacuated in May 12 deaths in West Bengal Cyclone Nisarga India (Maharashtra) More than 13 000 people in Raighar district of Maharashtra evacuated from 01-04 July 6 deaths in Maharashtra 2020-2021 SARS-CoV-2 pandemic All countries in the Region Over 36 million cases as of 13 July 500 000 deaths as of 13 July Source: Adapted from the Regional framework on operational partnerships for emergency response (SEA), with updated data from the WHO Health Emergencies Programme. Learnings from a decade of Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 10 The global WHO Health Emergencies Programme was formulated and became active in August 2016 to work with Member States in all phases of emergencies, from risk reduction and preparedness to response and recovery. The Global Preparedness Monitoring Board (GPMB) was established in 2017, following recommendations made by United Nations Secretary-General’s Global Health Crises Task Force the same year with political leaders, agency principals and international experts. It provides independent and comprehensive appraisals of the progress towards increased preparedness and response capacity for disease outbreaks and emergencies with health consequences. Following the setting up of the global programme, the WHO Health Emergencies Programme was established in the Regional Office for South-East Asia to support strengthening of emergency preparedness and response capacity of Member States. Identifying risks and systems for risk management To enable evidence-informed planning, a comprehensive analysis was undertaken in 2017 resulting in the publication of Roots for resilience: a health emergency regional risk profile of the South-East Asia Region.(1) This was an important landmark on the path to strengthening emergency preparedness and formed a baseline for mapping, monitoring, planning and reducing existing and potential risks, hazards and vulnerabilities. The analysis showed that existing capacities in the Region did not match the prevailing and ever-increasing threats. (Read more in Chapter 2) Improved understanding of risks, hazards, vulnerabilities and the increasing exposure of populations in the region, facilitated investments in capacity- building in relation to IHR compliance. The launch of the IHR in 2007 marked a new era of international cooperation for management of international public health events and emergencies. Since 2016, States Parties have been checking their progress on IHR compliance through mandatory self-assessment using the State Party annual reporting tool, and three voluntary mechanisms, namely simulation exercises, (26) after action reviews (27) and JEE.(28) All countries of the region complied with SPAR. The results to date show that considerable progress has been achieved in the areas of legislation, coordination, surveillance, response, risk communication, laboratory systems and zoonoses (Fig. 2b). However, there still remains constrained capacity of human resources in terms of IHR NFPs across the region, especially in epidemiology, vector control, infection control, travel medicine, risk communication, emerging and re-emerging diseases, and management of mass gatherings and Points of Entry (PoE). According to the JEE of IHR capacities conducted in eight countries of the region, existing capacities in relation to biological, chemical or radio nuclear threats, control of disease transmission at ground crossings, biosafety and biosecurity in laboratories, antimicrobial resistance (AMR) and management of cross-border conflict situations in the region are limited (Fig. 2a).(29,30) Five countries of the region have conducted AAR, and Indonesia and Nepal have conducted simulation exercises involving various stakeholders including WHO. A regional training workshop in September 2019 on how to design and conduct simulation exercises and AAR imparted required knowledge and skills to the participants, who included representatives of the Member States and WHO country offices. The region has acted upon its concerns about climate change and resultant extreme weather conditions detrimental to health. In 2017, the WHO Regional Committee passed a resolution SEA/RC70/R1 endorsing the Malé Declaration and the Framework for action in building health systems resilience to climate change in South-East Asia Region, 2017–2022. (16,17) For a country or region to be prepared to minimize impact of any hazard or emergency, its systems, plans and people must be fully cognizant of prevailing risks, hazards and vulnerabilities, and it must integrate risk- informed planning in all its development processes. 11Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Damage to health care infrastructure, physical injuries to individuals and loss of or separation from family members may result in discontinuity of treatment and care of patients with noncommunicable diseases (NCDs). To ensure continuity of NCD care in emergencies, a comprehensive guideline, Integration of NCD care in emergency response and preparedness was developed in 2018. To further ensure continuity of treatment and disaster preparedness in hospitals, an innovative Hospital Safety Index was introduced in 25 hub hospital networks in and around Kathmandu, Nepal, in 2019, and training provided to staff. Bhutan, India, Indonesia and Thailand also introduced initiatives to assess health facilities on their preparedness for multiple hazards. Implementing plans and initiatives Prioritization of emergency risk management under the regional flagship priority programme following the “sustain, accelerate and innovate” approach since 2014 has driven the development and implementation of various plans and initiatives with focus on emergency preparedness (Table 1). Examples of prioritizing emergency preparedness by Member States in the region are provided in Box 1. A major milestone on emergency preparedness was the development of two regional strategic plans in consultation with Member States and endorsement of these plans by the WHO Regional Committee in 2019. The Committee approved and launched two key regional strategies for Member States to adapt. The Five-year regional strategic plan to strengthen public health preparedness and response: 2019–2023 (21) was prepared based on a situational analysis of progress on IHR implementation in the region, gaps and opportunities identified from the eight JEEs completed during 2016–2018, and a regional consultation with the IHR NFPs and partners in New Delhi in March 2019. It is aligned with the global strategic plan and one of the three strategic priorities – 1 billion more people better protected from emergencies – of WHO’s Thirteenth general programme of work 2019–2023. It is also in line with the Bangkok principles for implementation of health aspects of the Sendai framework for disaster risk reduction 2015–2023 of March 2016. It aims to strengthen capacities of IHR NFPs on public health preparedness and response by refocusing on identified gaps, developing robust monitoring mechanisms, and improving networking and collaboration. The Risk communication strategy for public health emergencies in the WHO SEA (22) aims to ensure that each Member State builds and uses a multilevel, multisectoral and multifaceted risk communication plan to enable individuals, families and communities to make informed decisions to mitigate the effects of emergencies and take protective and preventive actions. It lays down a framework for Member States and WHO to strengthen critical capacity in five key areas of risk communication systems, internal and partner coordination, public communication, community engagement, and public preparedness, risky behaviour and misinformation. To ensure continuity of NCD care in emergencies, a comprehensive guideline, Integration of NCD care in emergency response and preparedness, was developed in 2018. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 12 FIGURE 2a: Regional average scores (on a scale of 0 and 100) for joint external evaluations, 2016–2018a FIGURE 2b: Regional average scores (on a scale of 0 and 100) for State Party annual reporting in 2018 IHR : International Health Regulations, 2005. Average scores across eight countries of the region in 19 technical areas IHR : International Health Regulations, 2005. Average scores across eight countries of the region in 19 technical areas Risk communication Points of entry Chemical events Radiation emergencies National legislation, policy and financing IHR coordination, communication and advocacy Zoonotic disease Antimicrobial resistance Biosafety and biosecurity National laboratory system Emergency preparedness Emergency response operations Linking public health and security authorities Medical countermeasures and personnel deployment Human resources Reporting 86 5554 40 3453 61 42 48 42 34 54 58 67 59 43 50 55 45 Surveillance Immunization Food safety 61 70 60 52 67 79 64 57 61 66 61 46 46 Legislation and financing IHR coordination and NFP functions Zoonotic events and human-animal interface Food safety Laboratory SurveillanceHealth service provision Risk communication Points of entry Chemical events Radiation emergencies Human resourcesNational health emergency framework 13Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Sustain Accelerate Innovate Continued strengthening of the health emergency operations centres (HEOC) network during 2016-2018 through training and onsite support to national HEOCs in all countries of the region Continued strengthening of national emergency medical teams (EMTs) Thailand type 1 EMT verified and recognized under the WHO EMT initiative on 31 July 201932 Establishment of South-East Asia Regional Knowledge Network of HR National Focal Points and experts to: ĥ create an IHR-focused community of practice ĥ host a regional knowledge repository on IHR implementation, best practices, research and innovation IHR monitoring and evaluation (as of 2019): ĥ 100% compliance with State Party annual reporting ĥ 8 of 11 countries conducted joint external evaluations ĥ after action reviews (5 countries), simulation exercises (2 countries) and regional training conducted Partnerships and resource mobilization of countries, focusing on: ĥ leveraging domestic funding ĥ preparedness and response streams of the South- East Asia Reginal Health Emergency Fund ĥ other sources (e.g. donors, development banks) Resource mobilization strategy developed and in implementation New partnerships in areas such as HEOCs, EMTs, chemical, biological and radionuclear events, and the Global Outbreak Alert and Response Network Development of a regional road map for high-threat pathogens, with expert consulations on Nipah virus and cholera conducted in October– November 2019 One Health Asia-Pacific, regional tripartite coordination mechanism, with a secretariat in Bangkok33 Monitoring and evaluation of the implementation of national action plans for combating antimicrobial resistance Linking/integration of pandemic preparedness plans with national action plans for health security Training in emergency response operations: ĥ Inter-Agency Standing Committee Health Cluster coordination, information management ĥ training consortium on operational partnerships Mapping operational partnerships for emergency preparedness and response Capacity development in emergency risk management scaled up and integrated into WHO country offices’ emergency preparedness and response plans. Promotion and implementation of One Health approach through National International Health Regulations-Performance of Veterinary Services workshops (Bangladesh, Bhutan, Indonesia, Myanmar) Uninterrupted emergency logistics and supply chain system Piloting and rollout of the Hospital Safety Index plus (HIS+) mobile application in Nepal Coordinating complex ongoing protracted Grade 2 emergency response to the Rohingya crisis in Cox’s Bazar, Bangladesh As of 2019, national action plans for health security developed and under implementation in Bhutan, Indonesia, Maldives, Myanmar, Sri Lanka, Thailand and Timor-Leste Roll-out of Go.Data 2.0, an innovative data management, analysis and decision-making tool34 Continued operational readiness training in WHO country offices and ministries of health35 Implementation of strategies for 2019-2023: ĥ Five-year regional strategic plan to strengthen public health preparedness and response22 ĥ Regional risk communication strategy for public health emergencies in the WHO South-East Asia Region23 Table 2: Flagship priority programme on emergency risk management: sustain, accelerate and innovate Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 14 Examples of successful emergency preparedness priority activities by Member States Bangladesh. Cyclone shelters; early warning and evacuation for Cyclone Fani in 2019 Bhutan. Seismic assessment of a hospital and non-structural corrective interventions Democratic People’s Republic of Korea. Pandemic influenza preparedness planning; laboratory strengthening India. Management of Nipah virus outbreak in Kerala in 2018; response to Kerala floods in 2018; early warning and evacuation for Cyclone Fani in 2019 Indonesia. Investment in recovery, capacity-building and preparedness after the Indian Ocean tsunami of 2004; strengthening of IHR capacities in 2008 following influenza A (H5N1) outbreak Maldives. Management of influenza A(H1N1) pdm09 outbreak in 2017; rapid response teams established at atoll level Myanmar. Capacities in surveillance strengthened through linking with District Health Information Software 2 (DHIS2) Nepal. Comprehensive earthquake risk mitigation and preparedness in the health sector, with linkages to relevant sectors; hospital safety assessments and use of a mobile application for hospital preparedness Box 1. Sri Lanka. Integration of mental health-care in emergency response; legislation and policies related to IHR; strengthened systems and capacities at district level Thailand. Investment in IHR core capacities and their overall integration into health systems; type 1 national emergency medical team verified by WHO; risk communication systems and plans Timor-Leste. Recovery from the 1999 East Timorese crisis and setting up systems for preparedness at district level 15Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Interlinking sectors and networks In order to strengthen intersectoral synergies, partnerships and collaboration among public and private stakeholders and operational partners for emergency preparedness and response, the Regional framework on operational partnership for emergency response (SEA Region)(3) was developed in 2017 to guide Member States, WHO country offices and partners on building operational partnerships in pre-emergency, emergency and post-emergency phases. Efforts to develop, foster and strengthen partnerships and networks through engagement of emergency medical teams, (37) GOARN, (38) the Standby Partnership, (39) Inter- Agency Standing Committee Health Cluster (40) and private stakeholders are being pursued continuously. In September 2018, the WHO Regional Committee for SEA passed resolution SEA/RC71/R5 on strengthening national and international emergency medical teams (EMT) in the region. The establishment of the regional knowledge network of IHR NFPs and domain experts created an innovative online platform for enabling peer-to-peer learning through an IHR- focused community of practice. It provides opportunities for exchanging ideas, consultation and discussion on IHR notifications and problematic issues in an informal online environment. Efforts to build partnerships and collaborations have not been limited to the Region and have been expanded through the Asia Pacific strategy for emerging diseases and public health emergencies (APSED III) in relation to all hazards. Delhi Declaration on Emergency Preparedness A continued push following the “sustain, accelerate and innovate” approach on emergency risk management under the regional flagship priority programme since 2014 has sustained a focus on strengthening emergency preparedness in the region. This culminated in the adoption of the ministerial-level Delhi Declaration on Emergency Preparedness at the WHO Regional Committee for SEA meeting in 2019. It reflects the strong political commitment of the Member States to increase investment in building resilient health systems, implementing national action plans for health security, and strengthening networks and intersectoral coordination mechanisms following the One Health approach. Various strategies, plans and political commitments have been made since 2006. Now it is time to convert these commitments into actions. Generating evidence, guidelines, strategic plans and political declarations without commensurate actions is not only irresponsible public health practice but also amounts to negligence with regard to the safety and protection of populations of this region amid known and unknown health risks and threats. Challenges Strengthening emergency preparedness is not limited to risk identification, risk mapping and development of strategic plans. It requires time and resources to make any population, system, country or region resilient to prevailing risks and threats. The following key challenges are indicative of the constraints that the regional flagship priority faces: ĥ need for repetitive spending by Member States and partners on emergencies of a seasonal nature and the danger of not investing enough to prevent or mitigate prevailing risks; Emergency preparedness is a long-term investment, the results of which are visible at times of disaster or emergency when loss of lives and damage to critical infrastructure are seen to be minimized. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 16 ĥ lack of investment in addressing drivers of risks,"all-hazards" emergency preparedness, and building back better because: z there are competing priorities within and outside the health sector z investors are not always rewarded with results and greater visibility within a limited time period ĥ lack of resilience of health systems at subnational and local level; ĥ lack of risk-informed development planning for the long-term at national and regional levels; ĥ lack of interest from private sector stakeholders in building resilient systems, despite the existence of laws on corporate social responsibility; ĥ inadequate budgetary allocation for and domestic funding of the health sector; ĥ innovative financial instruments for financing preparedness not yet fully explored; and ĥ limited use of technology for preparedness and response in the health sector. Financing of health emergency preparedness has been a challenge. To address it, an important strategic decision was taken in 2016 to embolden emergency preparedness in the region. Regional Committee resolution SEA/ RC69/R6 endorsed the expansion of the mandate of the SEAREF to include an additional financing stream focused on preparedness. (15) The Fund needs © W H O /S EA RO 17Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region This chapter has been adapted from the WHO South-East Asia Journal of Public Health, April 2020. It is authored by Drs Roderico H Ofrin, Anil K Bhola, Nilesh Buddha, World Health Organization Health Emergencies Programme, World Health Organization Regional Office for South-East Asia, New Delhi, India further financial support from donors to help and assist countries in DRR, preparedness and operational readiness. During the 72nd session of the Regional Committee in September 2019, the Union Minister of Health and Family Welfare, Government of India, pledged a contribution of US$ 200 000 to the preparedness stream for strengthening disaster and emergency preparedness.(41) The WHO Regional Office for SEA also developed a resource mobilization strategy and orientation manual to accelerate its fundraising.(42) Despite progress on emergency risk management and strategic interventions to boost emergency preparedness, countries’ existing capacity to respond to health emergencies do not seem adequate in the regional context of high burden of disease, frequent disease outbreaks, and a growing number of risks and hazards (Table 1). This raises the question “Are we adequately prepared to withstand any unexpected emergency or disaster, and combinatios of them?” Identification, mapping and mitigation measures in relation to risks, hazards and vulnerabilities facilitate strengthening of emergency preparedness and operational readiness. Since 2005, given the region's high vulnerability and significant exposure to natural hazards, disease outbreaks and human- induced disasters and emergencies, has strategically shifted from investing in emergency response to investing in risk reduction and emergency preparedness. There has been an increase in IHR core capacities. However, the IHR NFPs across the region need to improve capacity in certain areas with more impetus and investments in emergency preparedness; readiness to deal with any unexpected chemical or radio nuclear emergency; enhancing biosafety and biosecurity in laboratory networks to curb increasing AMR due to weak medical counter measures and delayed personnel deployment; and improving prevention and control of disease transmission at PoE.(43) Strong political commitment and budgetary allocation for investment in emergency preparedness and DRR are needed to sustain the health development gains. Member States should prioritize NAPs for health security and mobilize domestic funding and support from partners to implement the same. Innovative financial mechanisms need to be tapped to raise funds from donors and bilateral agencies in the region to finance emergency preparedness and risk reduction. Member States must fulfil their commitment to the four I’s of the Delhi Declaration: (i) identify risks, (ii) invest in people and building resilient systems, (iii) implement plans and (iv) interlink human, animal, wildlife and environmental sectors, following an ecological public health approach and strengthen existing networks. Emergency preparedness is a continuous task and a top priority for achieving comprehensive development and health security in the region and the world. Emergency preparedness is a continuous task and a top priority for achieving comprehensive development and health security in the region and the world. CONCLUSION

2 C H A P T E R Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 20 © W H O /B an gl ad es h 21Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region REGIONAL RISK PROFILE & VULNERABILITIES Throughout history and until SARS-CoV-2, untoward events, epidemics and disasters have devastated human lives. Despite advancements in preparedness and mitigation, no guarantees are assured for the safety and well-being of people against the onslaught of large- scale disasters and disease outbreaks. In developing countries, events caused by climate change and displacement due to public health emergencies have increased vulnerability of communities and nations. High density of population, poverty, lack of awareness and infrastructure gaps have made the severity graver. Systematic risk assessments followed by mitigating measures and investments in resilient infrastructure can improve preparedness and reduce the scale and loss of lives in future disasters. AN ALL-HAZARDS APPROACH Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 22 T he Indian Ocean Tsunami of 2004 was a turning point in the history of disasters in SEA. In a matter of hours, six countries in the Region were devastated by giant waves claiming thousands of lives and affecting millions. The unprecedented scale and intensity of the disaster led health sectors of countries to review their delivery systems to meet similar and emerging health challenges. Local health capacities and infrastructure systems were fortified; people were trained in emergency preparedness and response; damaged hospitals were rebuilt and new ones planned. Government and health agencies realigned themselves from a position of managing emergencies to managing risks. They worked closely with health care teams, measuring their capacities to lead while making new investments in training human resources. They realized that they needed to make clear investments prior to the events, focusing instead on responding during and after events. The SARS outbreak in 2003, avian influenza (H5N1) outbreak in 2005, H1N1 Influenza pandemic in 2009, Ebola virus disease outbreak in West Africa in 2014– 2016 and the COVID-19 pandemic have provided their share of learnings. From these disastrous events, opportunities have emerged and partnerships within and across sectors formed as countries now focus on building back better even as they prepare for the next big emergency. © W H O /D er m ot T at lo w 23Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Strengthening national capacities for emergency risk management Most countries of the SEA Region are low- or low-middle-income, with competing priorities in the area of development and growth. In addition to the changing epidemiological and disease profile which is dominated by the double burden of infectious and noncommunicable diseases (NCDs), there are challenges in integrating the health sector’s emergency preparedness with overall national disaster preparedness and response agencies and plans. The concept of investment and management across different phases of the emergency are yet to be fully addressed by policymakers.(44) According to the standard definitions developed by the United Nations International Strategy for Disaster Reduction (UNISDR), hazards cause serious disruption in the functioning of a community or society involving widespread human, material, economic and/or environmental loss and impact.(45) Often, these impacts exceed the ability of the affected community or society to cope using its own resources. This gap between the impact and the coping mechanism of affected persons exacerbates their exposure and vulnerability to risks. The risks by themselves result from a combination of hazards and vulnerabilities. Both risks and vulnerabilities are associated more strongly with poverty and the inability of communities to deal with it, largely due to capacity issues. (Fig 1) The overwhelming of health systems during the ongoing COVID-19 pandemic has highlighted the need to estimate hazards, vulnerabilities, risks and capacities in ways that can pre- empt some of the natural and human- induced disasters. © W H O /M ya nm ar Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 24 FIGURE 1: Adopting an “all hazards” approach for a wide range of emergencies Source: Roots for resilience: A health emergency risk profile of the South-East Asia Region, WHO 2017 25Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region A first-of-its kind Regional “risk atlas” mapped risks in a way that results and findings served as a tool for policy- makers to prioritize risk management in vulnerable areas. The findings highlighted two major changes in the Region, namely a scenario where epidemics turned into disasters and disasters caused epidemics with global impact; and where countries began to respond to emergencies from being event-based to risk-based. There is increasing recognition of emergency risk management calling for coordinated action across local, national, regional and international levels. As countries, states and communities assess their needs and look at the entire spectrum of hazards, be it biological, natural, human generated or technological, they also evaluate how these impact them and their populations. Strengthening emergency risk management must include advocacy, information management, technical and operational support, preparedness and response and partnerships. The primary objective in an emergency is to reduce avoidable loss of life and the burden of disease and disability. The idea of disaster risk management adopted by the Sendai Framework in 2015, is still new. It called for enhanced cooperation between health authorities and stakeholders at global and regional levels to strengthen country capacity for disaster risk management for health, implement IHR (2005) and to build resilient health systems. The “all-hazards” approach (natural, chemical, biological, radio- nuclear, humanitarian conflicts) to risk management is yet to be institutionalized across countries. As a 15-year, voluntary, non-binding agreement, the Sendai Framework recognizes the State’s primary role in reducing disaster risk and sharing this responsibility with local governments, private sector and other stakeholders. Risk assessments and evaluations guide country preparedness levels With the establishment of the WHE Programme in 2016, health emergency risk management was once again identified as a core priority. In 2017, a first-ever risk assessment and mapping was undertaken for all 11 countries of WHO’s SEA Region. The multi-hazard study provided an overview of hazards, vulnerabilities and risks through a profile based on scientific analysis of risks against available capacities. (46) In terms of disasters, the five disasters that were analyzed included earthquakes, floods, tsunamis, tropical cyclones and droughts. The assessment for diseases defined a methodology with existing tools and datasets to quantify risks and analyzed these through the prism of health status and capacities. The five syndromes and corresponding priority diseases that were assessed included severe acute respiratory illness represented by the Middle East Respiratory Syndrome (MERS-CoV), acute watery diarrhoea represented by cholera, acute haemorrhagic fever represented by Crimean–Congo haemorrhagic fever (CCHF), acute encephalitis syndrome represented by Japanese Encephalitis (JE) and acute febrile illness with rash represented by the Zika virus disease (ZVD). It drew key action points and recommendations to address these risks in the immediate, medium and long-term. (47) The findings helped identify gap areas, with suggestions on addressing vulnerabilities by Member States. It relooked the hazards, risks and capacities to develop a clearer strategy for risk reduction, preparedness and investment. The assessment provided clarity on the interrelationship of vulnerability, hazards and capacities while quantifying risks. The risk profiling of the Region was based on the INFORM Risk Index methodology.7 (48) For the assessment, only natural hazards were included and risk was estimated based on the three main dimensions of hazard and exposure, vulnerability and lack of coping capacity. (Table 1). 7 An open-source platform of global risk assessment for humanitarian and disaster crises used for disasters, covering earthquakes, tsunamis, floods, cyclones, droughts and protracted human conflicts. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 26 Table 1: INFORM Risk Index of natural hazards Country Hazard and exposure Vulnerability Lack of coping capacity INFORM riskEarthquake Flood Tsunami Tropical cyclone Drought (0-10) (0-10) (0-10) (0-10) (0-10) (0-10) (0-10) (0-10) Bangladesh 8.7 10.0 8.5 7.0 5.1 4.6 5.4 5.7 Bhutan 7.4 5.2 0.0 0.0 0.0 3.0 4.6 2.9 DPR Korea 0.9 7.7 3.2 6.6 2.9 5.1 6.7 5.5 India 7.9 8.5 8.3 7.6 6.9 5.4 4.6 5.7 Indonesia 8.4 8.2 9.6 6.4 3.6 2.3 4.9 4.3 Maldives 0.1 0.1 8.9 0.0 0.0 1.5 4.1 2.2 Myanmar 9.3 10.0 8.5 5.7 1.1 5.9 6.4 6.6 Nepal 9.9 6.5 0.0 0.2 2.9 4.9 5.9 5.4 Sri Lanka 0.1 6.2 8.2 3.5 3.4 3.6 4.1 4.1 Thailand 3.4 8.9 6.8 4.9 6.1 2.9 4.1 4.0 Timor-Leste 5.7 1.9 5.0 3.7 0.3 5.0 6.8 4.1 © W H O /D PR K or ea 27Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Mapping the Region’s disaster and disease risk profiles The Region has been exposed to nearly all kinds of natural hazards and disasters such as periodic typhoons, tropical cyclones, floods, droughts, earthquakes, tsunamis, volcanic eruptions, landslides, forest fires, haze and pandemics besides experiencing agricultural and resource risks, as well as those linked with rapid urbanization, migration and socioeconomic changes. For natural hazards, what increases vulnerability of countries is their sharing of common geological formations and river basins as well as coastal belts, forcing natural hazards to transcend national boundaries.(50) With continuing increase in scale and frequency of disasters, economic costs associated with these events too are increasing along with number of casualties. Majority of countries in the region are low- or middle-income and undergoing demographic transition. Member States host 40% of the world’s poor, who face multiple challenges, making them highly vulnerable to extreme events that include humanitarian emergencies and disease outbreaks. (51) Haphazard and unplanned urbanization, development in and around high-risk areas, overcrowding and poor housing, migration, poverty, climate change and poorly functioning health systems aggravate risk factors and impede recovery. (Fig 2) Examples of effective disease risk mitigation in the Region include dengue prevention and control in Thailand, clinical management of cholera in Bangladesh, elimination of measles in Bhutan and Maldives ahead of the 2020 Regional target, malaria control in Timor- Leste and effective containment of MERS in Thailand.(49) © W H O /S ho bh an Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 28 Multiple factors contribute to India’s high vulnerability to natural and man-made disasters India is prone to all major natural hazards and has experienced a number of disasters that have seen an increasing trend in terms of events and casualties over the last four decades. About 60% of its landmass is prone to earthquakes of varying intensities, over 8% to floods, 75% of the coastline is prone to cyclones and 68% of its area is susceptible to drought. Direct losses resulting from disasters are estimated to be in the region of approximately 2% of the country’s GDP which is considered very high. Sri Lanka tries to tide over a conflict- ridden past and vulnerability to cyclones and floods Sri Lanka’s geographical and climatic diversity exposes it to a number of nature-induced risks, with the majority of hazard events being floods, droughts and cyclones. The country still recalls the chilling impact of the 2004 Indian Ocean Tsunami. Overall, floods have cumulatively affected more than 10 million people, while droughts have affected over 6 million in the past. Droughts occur three to four times a decade causing enormous economics setbacks. Though less frequent, cyclones have impacted the lives of those living along the coastal belt. The country has had its share of landslides in the hilly central highlands. Sri Lanka’s bitter past had several conflicts and unrests, leading to riots and violence that have taken a toll on the social and economic health of the nation. Sea level rise puts Maldives at even more risk Maldives is vulnerable to storms, tsunamis, excess rainfall and sea level rise. It is situated in the Indian Ocean with an archipelagic group that comprises 1 196 coral islands grouped in 26 atolls, of which 200 islands are inhabited and exposed to cyclones. While high impact events are relatively infrequent, the country has experienced major disaster events, including the 2004 Indian Ocean Tsunami and is confronted with a series of challenges related to Maldives is the lowest-lying country in the world and resultantly, sea level rise sea level rise will impact the protective capacity of its coral reefs, increase the salinity of its groundwater resources, besides increasing the strength of cyclones, flooding and inundation on its shores. Bangladesh’s strong disaster history guides its future planning efforts Bangladesh has faced numerous disaster in the past and continues to remain highly hazard-prone, due to earthquake zoning and physical exposure to flood, cyclone and tsunami. The country is also vulnerable to existing health conditions, high population density, narrow roads, congested industries in cities and extreme events. Overall, the country has come a long way in its efforts to manage and control disasters and should continue to strengthen disaster planning in its long-term development goals and practices. Earthquakes and extreme weather events threaten the tranquillity of mountainous Nepal Nepal is a landlocked country with diverse geographical and climatic features that expose to a number of natural hazards. The country frequently experiences landslides, debris flows, floods, earthquakes and glacial lake outburst floods. In recent years it has faced some of its worst earthquakes, landslides and floods, weakening its fragile economy. It is located in a seismic Zone V (highly hazard prone) area. The 2015 Great Himalayan Earthquake in Nepal caused immense damage to life and property. Recurring flood, avalanches and windstorms are the other reportable disasters. Lately, experts are cautioning the impact of climate change and extreme events on Nepal. MYANMAR BHUTAN NEPAL THAILAND BANGLADESH SRI LANKA MALDIVES FIGURE 2: Regional snapshot of disasters INDIA hea th emerg ncies i the South-East Asi Region 29Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Bhutan, protected so far, but may face climate induced events in the future Bhutan is a landlocked country, which has not faced any severe disaster so far. However, there are a number of potential hazards which loom on the horizon, especially with physical exposure to earthquakes because of high level of zoning in the country. Other applicable hazards are glacial lake outburst flood (GLOF), landslides, fires and windstorms. The country is vulnerable to the existing health 4th Assessment Report of the Intergovernmental Panel on Climate Change (IPCC) which estimates that Bhutan will see climatic- induced changes in its mountainous ecosystem that could exacerbate its natural hazards. Indonesia’s constant battle with a range of natural disasters Indonesia is the world’s largest archipelago and its particular geographical and geological characteristics place the country among those which are the most vulnerable to natural hazards. It has more than 500 volcanoes, of which128 are active. It is subject to a high level of seismic activity, given its location at the intersection of three crustal plates. Most of these occur at sea, bringing in added risks of tsunamis for tidal waves. Many parts of the country are susceptible to droughts and forest fires. Indonesia also has over 5 000 small and big rivers, of which 30% cross a high population density area, posing as flood hazards. Additionally, the country has faced a number of storms in the past. Timor-Leste’s vulnerability to natural hazards can be minimized with improved infrastructure Timor-Leste is located in the southernmost part of the SEA Region on the eastern half of the island of Timor. Its global risk rank is 69 as per the INFORM Risk Index, and ranks seventh in the SEA Region. It is prone to severe and recurrent droughts, flooding, landslides, tropical cyclones and tsunamis. Its location near the intersection of three continental plates makes it vulnerable to major earthquakes. Frequent landslides and flash floods disrupt the land transport system by destroying bridges and damaging roads. Drought is a major problem, and puts pressure on food security. Being a low-income country, it is constrained in terms of infrastructure and unless this is developed, it will continue to get severely impacted by disaster events. Thailand is most impacted by floods and tsunamis Thailand is located in the centre of the SEA peninsula. The country’s global risk rank is 80 as per the INFORM Risk index, and it ranks eighth in the SEA Region. It is vulnerable to natural hazards, including floods, tsunamis, storms, droughts, landslides, forest fires, earthquakes and epidemics. Among natural hazards, tsunami causes the largest number of deaths while floods affect the largest number of people. Droughts have also been a significant hazard in the country. Apart from these, cyclonic storms have caused significant damage. There have been around 30 storms in the past three decades, killing over 1696 people, affecting more than 3.2 million people and causing an economic loss of $911 million. Geographical constraints and limited resources heighten Myanmar’s exposure to disasters Myanmar is one of the most resource constrained countries in the SEA Region. This limits its capacity to deal with nature’s onslaughts. Its natural geographical conditions make it most vulnerable to natural hazards, including cyclonic storms, floods, earthquakes, tsunamis, forest fires, landslides and epidemics. Having a long coastline along the western part of the country, the Bay of Bengal, Myanmar is regarded as a cyclone vulnerable area. With heavy rainfall, it experiences frequent flood events besides earthquake, landslides and storms-induced changes in its mountainous ecosystem that could exacerbate its natural hazards. DPR Korea’s vulnerability to disasters requires scaling up of Capacities The Democratic People’s Republic of Korea is located in East Asia. Due to extreme weather conditions, it experiences some of the most frequent disasters, including flooding, torrential rains, typhoons and storm surges, year after year. This has led to soil erosion and sedimentation bringing on landslides, droughts, duststorms and sandstorms. A number of major flood events have occurred in recent years, resulting in economic loss (particularly to agriculture), damage to infrastructure and loss of life and livelihood. Strengthening communication networks, forecasting constraints and local coping capacities are some of its priority areas as it braces itself to withstand and manage disasters and outbreaks in the coming years. INDONESIA TIMOR-LESTE DPR KOREA Source: Roots for Resilience: A Health Emergency Risk Profile of the SEA Region, WHO 2017 Learnings from a decade of Disclaimer: The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 30 Countries in the region remain constantly exposed to outbreaks and epidemics of emerging and re-emerging diseases including waterborne, vector-borne, vaccine-preventable, respiratory and zoonotic infections. Post-event analysis of most recent outbreaks provided important lessons. This included Influenza A (H1N1), MERS-CoV, avian influenza A (H5N1), A (H9N2), Nipah virus, JE and CCHF, highlighting how early warning of emerging and re-emerging infections depends on the ability to identify the unusual as early as possible. The 2003 SARS epidemic showed how rapid and coordinated interventions could produce effective results while the ongoing COVID-19 pandemic has put the spotlight on health systems strengthening. All risks, vulnerabilities and capacities can be measured with existing indices such as INFORM and the UHC Index, as well as existing metrics like SEA Region Benchmarks and IHR monitoring and evaluation tools. However, these need to be adapted to the context of the country for greater effectiveness. The risk assessment for infectious disease threats revealed that the Region is vulnerable to all threats. Vector-borne and zoonotic diseases appear to be at a greater risk to the Region than diseases transmitted by other modes. Although IHR self- assessment estimated a higher disease containment capability, disease-specific and country-specific vulnerability assessed by regional experts provided a more nuanced understanding of the local situation, as exemplified by largely minimal or nil surveillance in both human and vector/source/reservoir sectors, including zoonoses. Thailand has often been considered as a best practice model for dengue control and management. Timor-Leste was assessed for high risk of JE, MERS and cholera, mainly due to system-wide weaknesses related to surveillance, laboratory capacity and disease containment. Also, nearly 60% of its population lacks access to improved sanitation facilities and 70% of the area provides favourable ecology for the JE-transmitting vector, Culex tritaenorrhyncus. Regional vulnerabilities influence local vulnerabilities, even when local transmission of a disease is absent. For example, several countries had not reported MERS and CCHF but continue to be at high risk for both. In case of VBDs especially, this is supported by presence of the vector and therefore ecology suitability. (52) The 2003 SARS epidemic showed how rapid and coordinated interventions could produce effective results while the ongoing COVID-19 pandemic has put the spotlight on health systems strengthening. © W H O /S ri La nk a 31Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region FIGURE 3: Towards greater resilience: next steps for countries and the Region Prioritizing risk reduction and preparedness There is urgent need to make a shift that allows implementation of an “all- hazards” approach that is relevant to multiple players and stakeholders. This comprehensive view will help address all possible health issues, needs and actions that must be in place well before any outbreak or disaster. This approach provides the strongest basis for conducting risk assessments and functional institutional response to critical events. Specifically, for actors in the health sector, improving UHC indicators will lead to an enhancement of capacities and reduction of risks at the same time. More knowledge and evidence through risk analysis at subnational levels are needed so that risk reduction and preparedness can be prioritized in a more granular manner (e.g. by area or population), and preparedness and risk reduction plans can be aligned to meet the challenges of the most vulnerable to ensure “no one is left behind.” It is necessary to expand the horizons from addressing single hazards to adopting the “all” hazards-focused approach that views the emergency from a more “whole-of-society” and multisectoral lens. (Fig 3) WHO Regional Office for SEA will continue to provide technical support for national efforts to assess risks, address vulnerabilities and build capacities as per regional and global frameworks and instruments. FIGURE 3: Towards greater resilience: next steps for countries and the Region Actions at regional and global levels Actions at subnational level Proceed with risk analyses at subnational level as guided at the national level in countries Develop a plan of action against priority risks Address vulnerability factors and capacity gaps in health Map work with other partners Monitor and evaluate as well as document work in order to feed into national actions Analyse risks by bringing together information on all hazards, vulnerabilities and health capacities Discuss IHR, SEA Region Benchmark capacities, UHC Index and INFORM Index reporting Support subnational risk analyses – technical and operational neds Prioritize actions as per risk and capacity and support these actions accordingly Compile all subnational risk analyses Report findings in global platforms as well as to regional and global frameworks and instruments Facilitate mobilization of resources Support national efforts to assess risks, address vulnerabilities and build capacities as per regional and global frameworks and instruments Conduct further analyses of risks at regional and global levels and develop joint plans accordingly Facilitate exchange of experiences and best practices Actions at national level Monitor and evaluate actions and provide support for any corrective action as needed It is necessary to expand the horizons from addressing single hazards to adopting the “all” hazards- focused approach that views the emergency from a more “whole- of-society” and multisectoral lens. Source: Roots for Resilience: A Health Emergency Risk Profile of the SEA Region, WHO 2017

3 C H A P T E R Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 34 © W H O /B an gl ad es h 35Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region COUNTRY PREPAREDNESS FOR PUBLIC HEALTH EMERGENCIES The WHO Regional Office for SEA, in consultation with Member States, partners and stakeholders developed and facilitated implementation of notable intergovernmental, global and region-specific policies, frameworks and strategies. National operational readiness has been enhanced with the ability to handle initial impact of emergencies and their recovery. WHO supports countries in meeting their commitments under IHR (2005) to ensure early detection, rapid response and recovery from all types of health emergencies. Focus is increasingly on managing imminent risks and threats of emerging and re-emerging pathogens with high-transmissibility. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 36 F ollowing the SARS outbreak in 2003, the revised IHR was endorsed, as the globally agreed legal framework for protecting global health security. IHR (2005) is the joint commitment for shared responsibilities against disease spread, calling for national core capacity requirement for surveillance and response, as well as regional and international alert and response systems. Building health security sytems requires long-term planning and investment. The Review Committee on the Functioning of the IHR in relation to Pandemic (H1N1) 2009 concluded, “the world is ill-prepared to respond to a severe influenza pandemic or to any similar global, sustained and threatening public health emergency.”(53) Following which, the post-H1N1 review of IHR drew attention to the many vulnerabilities in national public health capacities, limitations in scientific knowledge, difficulties in decision-making in the context of uncertainty, complexities in international cooperation and challenges in communication. Subsequent public health efforts were then directed towards strengthening health systems and building capacities at the national, regional and global levels to prevent, detect and respond to health emergencies. Despite these realizations and efforts, the response to COVID-19 highlighted the need for countries to be a lot more prepared to successfully contain and control the spread of similar outbreaks. 37Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Implementation of international and intergovernmental frameworks Emergency preparedness is addressed through the implementation of a range of global frameworks and initiatives that are adapted to local national contexts such as the Sustainable Development Goals, the International Health Regulations (2005), Sendai Framework for Disaster Risk Reduction (2015–2030), Pandemic Influenza Preparedness (PIP), World Organization for Animal Health (OIE) Performance of Veterinary Services (PVS Pathways), The Paris Agreement on Climate Change, Global Health Security Agenda (GHSA) and Universal Health Coverage (UHC) 2030. The International Health Regulations (2005) The IHR (2005) came into force on 15 June 2007 marking a new era of international cooperation for managing international public health events and emergencies. (54) They served as a valuable guidepost for national and international capacity building, coordination and collaboration for global health security. The COVID-19 pandemic, however, revealed gaps in compliance by State Parties with obligations under IHR, particularly on preparedness, contributing to the pandemic becoming a protracted global health emergency. In many instances, accountability mechanisms for evaluating and improving compliance with IHR needed further strengthening (55) (Read more in Chapter 6). © W H O /T ha ila nd The IHR (2005) came into force on 15 June 2007 marking a new era of international cooperation for managing international public health events and emergencies. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 38 Other international fora including Global Health Security Agenda (GHSA) and Health Security Initiative for the Indo-Pacific Region recognized the importance of IHR as a global framework and accordingly focused discussions on IHR-related core capacity building. (56,57) Consequently, implementation of IHR has become a priority world over with each region of WHO working towards being fully compliant.(58) Asia Pacific Strategy for Emerging Diseases. As emerging and re-emerging diseases, including zoonoses appeared in the SEA and Pacific regions, efforts to intensify collective preparedness and response through a common strategic direction were noticed. The bi-regional “Asia-Pacific Strategy for Emerging Diseases (APSED) developed jointly by the WHO Regional Office for the Western Pacific and the WHO Regional Office for South-East Asia in 2005 saw a much-needed revision in the form of APSED in 2010.(59) National Bridging Workshops (NBW) on IHR and Performance of Veterinary Services (PVS). The WHO and OIE have been active promoters and implementers of an intersectoral collaborative approach among institutions and systems to prevent, detect and control threats common to animals and humans, including AMR. The two organizations introduced the mechanism of holding a national bridging workshop to enhance collaborative work, complementarity and alignment of capacity building and strategies between human and animal health. The main objective being to provide an opportunity to human and animal health services of hosting countries to build on assessments conducted in human and animal health (IHR for public health and PVS for animal health); explore options for improved coordination; and to jointly strengthen their preparedness for, and control of, the spread of zoonotic diseases. These workshops help operationalize One Health, on one handwhile contributing to the development of the NAPHS, on the other. Pandemic Influenza Preparedness (PIP) Framework. The PIP Framework for sharing of influenza viruses and access to vaccines and other benefits adopted at the Sixty-fourth World Health Assembly in May 2011 became a landmark in country preparedness for pandemic response. The framework was designed to strengthen global pandemic influenza surveillance and response through private sector contributions, benefitting low- and middle- income countries (LMIC) by increasing access to technologies and strengthening countries’ capacities for pandemic response.(60) The Regional Office supported and facilitated Member States in SEAR to develop and implement national influenza pandemic preparedness plans (NIPPPs). To date, all 11 countries in the Region have NIPPPs, although at different stages of maturity. In Timor-Leste, NIPPP within NAPHS has been a good example of a blueprint for responding to and adopting of a framework for contingency planning for other high-threat pathogens.(61) The 2009 pandemic and subsequent seasonal influenza outbreak in countries like the Democratic People’s Republic of Korea, India, Maldives, Myanmar and Sri Lanka led to opportunities for establishing strong links with national emergency management structures through public health emergency centres. In 2020, the Global Influenza Surveillance and Response System (GISRS) and national Influenza laboratory networks proved effective as a preparedness resource for scaling laboratory surveillance for SARS-CoV-2. WHO’s Regional Office for SEA provided support in pilot testing National Bridging workshops in Thailand in 2014 and rolling them out in Indonesia in 2017, Bhutan in 2018 and Bangladesh in 2019. 39Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Sendai Framework for Disaster Risk Reduction. The Framework was adopted by 187 United Nations Member States in 2015, forming part of the 2030 Agenda for Sustainable Development.(62) Natural, technological, environmental and biological hazards are all within its scope for monitoring and reporting. The WHO technical guidance notes on Sendai Framework reporting by Ministry of Health (MoH) aims to guide the health sector on their role in collecting and reporting data that is relevant for the Framework’s targets and related frameworks.(63) The Regional Office advocated for, supported and facilitated Member States in implementation of health aspects of the Framework for DRR; notably hospital safety assessment in Nepal, Sri Lanka, Thailand, India, Indonesia and Bangladesh. Countries improved their early warning, alert and response systems (EWARS), risk communication, continuity of treatment for chronic health conditions, integration of mental health and psychosocial support services right from acute phase of emergency response to recovery phase, and improving the capturing of disaster impact data across age, gender and disability. The national health emergency focal point in respective MoH work in close collaboration with the national Sendai Framework focal point in the disaster management authority at country-level for implementing, monitoring and annual reporting of the Framework. The national health emergency focal point in respective MoH work in close collaboration with the national Sendai Framework focal point in the disaster management authority at country-level for implementing, monitoring and annual reporting of the Framework. © W H O /S EA RO Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 40 WHO Health Emergency and Disaster Risk Management Framework. The Health Emergency and Disaster Risk Management (HEDRM) Framework was released in 2019 (64) outlining a clear need for working together with all stakeholders. The WHO Regional Office for SEA in collaboration with the UNDRR Regional Office for Asia and the Pacific (ROAP) have been advocating with Member States through webinars and consultation meetings with the Sendai Framework NFPs to ensure active uptake and implementation of the Health EDRM Framework which aligns health security, disaster risk reduction, humanitarian reforms, climate change and SDGs.(65) The EDRM comprises the strategic assessment of risk (STAR) tool for designing EDRM strategies specific to local contexts, while following whole-of-society and whole-of-government approaches. The COVID-19 pandemic response has given an impetus to implement these approaches in Member Countries with operational guidance from WHO.(66) Table 1: Resolutions adopted by WHO Regional Committee for South-East Asia since 2004 on strengthening emergency preparedness Sessions No./SEA/RC Resolution SEA/RC57/R3/2004 Emergency health reparedness SEA/RC58/R6/2005 Health action in emergencies; including response to earthquake and tsunamis of 26 December 2004 SEA/RC59/R7/2006 Public health, innovation, essential health research and intellectual property rights SEA/RC60/R7/2007 South-East Asia Regional Health Emergency Fund SEA/RC62/R2/2009 Climate change and human health SEA/RC62/R5/2009 South-East Asia Regional Health Emergency Fund SEA/RC63/R3/2010 Coordinated approach to prevention and control of acute diarrheal and respiratory infections SEA/RC63/R4/2010 Prevention and containment of antimicrobial resistance SEA/RC63/R7/2010 Regional Strategy on Health Information Systems SEA/RC65/R7/2012 Strengthening health workforce education and training in the Region SEA/RC67/R6/2014 Strengthening health workforce education and training in the Region SEA/RC68/R2/2015 Response to emergencies and outbreaks SEA/RC69/R6/2016 Expanding the scope of the South-East Asia Regional Health Emergency Fund (SEARHEF) SEA/RC70/R3/2017 Male’ Declaration on building health systems resilience to climate change SEA/RC71/R5/2018 Strengthening emergency medical teams (EMTs) in the South-East Asia Region SEA/RC72/R1/2019 Delhi Declaration on Emergency Preparedness in the South-East Asia Region SEA/RC73/R1/2020 WHO South-East Asia Region Member States’ Declaration on Collective Response to COVID-19 41Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region WHO Regional Committee for South-East Asia. The WHO Regional Committee for SEA is the highest intergovernmental body in the Region, comprising representatives from its 11 Member States, as well as Associate Members. It meets every year to formulate policies, provide oversight for regional programmes, hear progress reports and consider, revise and endorse new initiatives and adopts resolutions. Table 1 provides a timeline of the resolutions addressing emergency preparedness approved by the Regional Committee. Setting-up of the SEAREF through resolution SEA/RC60/R7 in 2007 was the first key milestone reflecting high political commitment by Member States for providing financial backing to country emergency preparedness and response. (67) This was followed by another important step in 2014 when ‘scaling-up capacity building for emergency risk management’ was identified as a Regional Flagship Priority. To provide politic-administrative-financial backing to emergency preparedness at country-level, the scope of SEARHEF fund was expanded and a “Preparedness Steam” within it established.(68) Since then, various initiatives and innovative activities have been advocated, facilitated and supported by the Regional Office at country level for accelerating improved understanding about emergency risk management. It has also been building workforce strength in the health sector besides mobilizing operational partners for operational readiness for combined and effective emergency response.(69)As a result of these efforts, there has been significant progress on operational partnerships. The Thailand Emergency Medical Team (EMT) was verified and recognized under WHO EMT Initiative as Type 1 internationally deployable and EMTs in Bhutan, Indonesia and Sri Lanka are in the pipeline for getting verified. Regional level partnerships with the GOARN were strengthened and immediately deployable surge capacity boosted.(70) To provide politic- administrative- financial backing to emergency preparedness at country-level, the scope of SEARHEF fund was expanded and a “Preparedness Steam” within it established. © W H O /S EA RO Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 42 SEARHEF was established at the Sixtieth Session of the WHO Regional Committee for SEA in Bhutan, in 2007 via a special resolution effective January 2008. It formalized provision of assistance and facilitation of rapid response to natural and manmade disasters in the Region. This was a major development because till then emergency funding mechanisms took time to materialize and in the process lost valuable opportunity to reduce negative impact on people’s health. Political and administrative protocols took time for approvals before funds got released. With SEAREF, request for financial support was cleared in > 24 hours and funds upto USD 35 000 disbursed immediately.(71) SEAREF operated at two levels. One million US$ per biennium was sanctioned from WHO’s regular budget with all 11 countries contributing a fixed percentage to complete the target; and US$ 1.5–2 million was targeted as additional support to be mobilized by WHO’s Regional Office for SEA, from donors, countries and other agencies. As Member States began to avail of the fund, they also provided feedback to expand its scope of utilization and build capacity at country offices to process requests and strengthen resource mobilization efforts. (Read more in Chapter 12). What SEAREF means to the Region and how it can stay relevant The SEARHEF, since 2008, has released over US$ 6.77 million for 43 emergencies in 10 Member States across the region demonstrating strong regional solidarity and commitment of Member States to support each other against health emergencies. In the Biennium 2019–2021, US$ 700 000 were released from the SEARHEF for supporting COVID-19 response in Bhutan, Maldives and Thailand and to support immediate health needs due to flash floods and surge in COVID-19 cases in Timor-Leste.(72) In 2009, Timor-Leste made a contribution of US$ 100 000 as part of a voluntary contribution component of the fund. Despite availability of other funding sources such as the Central Emergency Response Fund (CERF) and the Contingency Fund for Emergencies (CFE), SEARHEF stands apart, being a regional fund exclusively for Member States while CERF is a global fund. On completion of 10 years, an evaluation study was commissioned by WHO SEARO in 2019. Member States felt that the limit of US$ 350 000 sanctioned as part of SEAREF funding was insufficient and needed an increase. Some felt the bifurcation of the total fund amount in two tranches of US$175 000 required revision. However, SEARHEF’s flexibility has been evident from the wide range of activities it supports, from procurement, surveillance, conduct of rapid assessments, operational cost of mobile health teams, etc. Some examples: Bangladesh. During the diphtheria outbreak at Cox’s Bazaar, SEARHEF was used for setting up lab facilities. During the 2017 Cyclone Mora, SEARHEF’s value addition supported mobile health teams with emergency medical supplies to speed up public health response and strengthen communicable disease surveillance helping reduce morbidity and mortality and contain outbreak of waterborne and VBDs. Nepal. Post the 2015 earthquake, the fund was used to activate the Health Emergency Operations Centre (HEOC), and procure drugs, mobilize and deploy hub and district-level coordinators. Myanmar. Post the 2015 floods, SEARHEF support came handy from rapid response teams of MoH to provide emergency and primary health-care services and reduce avoidable morbidity and mortality. (73) In the Biennium 2019–2021, US$ 700 000 were released from the SEARHEF for supporting COVID-19 response in Bhutan, Maldives and Thailand and to support immediate health needs due to flash floods and surge in COVID-19 cases in Timor-Leste. 43Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region The Regional Office provided hands-on support in facilitation and development of multisectoral and risk-informed NAPHS in Bhutan, Indonesia, Maldives, Myanmar, Sri Lanka, Thailand and Timor-Leste since 2017. Bangladesh too developed its NAPHS, and it is in the process of finalization. Meanwhile, the Regional Committee launched two key regional guidance documents in September 2019, apart from establishing the SEA Regional Knowledge Network of IHR and domain experts for informal exchange of experience, learnings and good practices. Guidance was provided to Member States in improving implementation of IHR (2005) and building core capacities for dealing with health emergencies. Development of national risk communication plans in Bhutan and Timor-Leste in 2019 and Regional risk communication strategy in 2019 which guided COVID-19 risk communication strategies in 2020, are few of the positive outcomes. Financing for national policies and action plans for health security are mainly from domestic funding in most Member States and in collaboration with stakeholders of global health security. International investment for emergency preparedness has been inconsistent despite creation of the ‘Preparedness Stream” under SEARHEF. Many donors, partners and Member States are yet to increase funding for emergency risk management while leveraging and tapping resources from non-health sectors and by engaging private sector and other non-government stakeholders. Sustaining advocacy and stewardship for domestic investment for preparedness is crucial for both WHO and its Member States and for the sustainability of preparedness and operational readiness. Sustaining advocacy and stewardship for domestic investment for preparedness is crucial for both WHO and its Member States and for the sustainability of preparedness and operational readiness. © W H O /S EA RO

4 C H A P T E R Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 46 © W H O /S EA RO 47Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region BUILDING RESILIENT HEALTH SYSTEMS WHO’s Regional Office for SEA, as part of the SEA Regional Flagship Priority Programme on Universal Health Coverage, is supporting countries to strengthen health systems to progress towards UHC in line with the Thirteenth General Programme of Work 2019–2023. WHO’s work on UHC is fully aligned with SDG target 3.8, which focuses on achieving UHC, including financial risk protection, access to quality essential health-care services and to safe, effective, quality and affordable essential medicines and vaccines for all. A resilient health system will depend on different components, both human resources and public health infrastructure. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 48 T he WHO’s SEA Region has witnessed vast gains in population health over the past decade. All countries in the Region showed an improvement in the overall essential health service coverage index8, with the regional average increasing from 49% in 2010 to 63% in 2020.(74) The infection prevention and control (IPC) and access to water, sanitation and hygiene (WASH) standards for infectious diseases are steadily increasing in health-care facilities across the Region. The IHR (2005) annual reporting data shows gradual increase in health service provision capacity from 56% in 2018 to 65% in 2018 when this indicator was first introduced in IHR annual Reporting(75) (Fig 1). However, progress largely remains uneven with regard to availability of case management services for priority epidemic-prone diseases at national, intermediate and local levels. Given this scenario, countries in the Region were hit hard by the COVID-19 pandemic. COVID-19 has negatively affected efforts to achieve system goals such as SDGs, and UHC building of resilient health systems. Besides its direct impact on health, it indirectly impacted the delivery of health services due to lockdowns and other public health measures. According to WHO Pulse surveys9 conducted in 2020 and 2021, all countries experienced disruption to essential health services, though to varying extent. Disruptions were reported on both the demand side (public reluctance to utilize health services during the pandemic and lockdowns hindering access) and supply side (cancellations of elective care and shortages repurposing of the health workforce to COVID-19 response) to COVID-19 response.(76) © W H O /T ha ila nd 8 Target 3.8 is defined as achievinge UHC, including financial risk protection, access to quality EHS and access to safe, effective, quality and affordable essential medicines and vaccines for all. 9 To better understand extent of disruptions to EHS caused by COVID-19, in early 2021 WHO launched the 2nd round of National pulse survey on continuity of essential health services during COVID-19 pandemic. The report presents global findings from 135 countries and territories that participated in the survey during January–March 2021. Findings offer insights from country key informants in impact of the pandemic on EHS across the life course; reasons for disruptions; and how countries are adapting strategies and approaches to maintain service delivery. 49Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Indeed, the pandemic has served as a sharp reminder of how easily overwhelmed health systems can become during public health emergencies and how resilience is a vital factor when responding to unexpected shocks, ensuring continuity in health improvement and strengthening of the system. The COVID-19 pandemic in particular highlighted the importance of re-orienting health systems to comprehensive and integrated primary health care, including capacity to support public health functions, in order to both address health emergencies and achieve UHC.(77) Role of financing in building resilient systems Financing serves as a foundation when it comes to planning and operationalizing national approaches to managing emergencies. Prior to COVID-19, LIMCs in SEA Region were experiencing transition with regard to health expenditure. Despite improvement in prioritizing the health sector in overall government spending over the past decade, domestic government spending on health continues to be low. Consequently, the Region retains the highest share of out-of-pocket health spending globally at 40% as of 2018. (74) In fact, the link between health sector planning and budgeting remains weak across the Region. In response to the pandemic, collaboration between countries and regional intergovernmental organizations was strengthened by establishing collective measures. For instance, the South Asian Association for Regional Cooperation (SAARC) enhanced its cooperation in the health sector to combat the virus at the regional level. A COVID-19 Emergency Fund of US$18 million was established for the benefit of all Member States.(78) Similarly, the Association of Southeast Asian Nations (ASEAN), as a regional body, stepped up national response and regional cooperation, complementing WHO’s work. The link between health sector planning and budgeting remains weak across the SEA Region. FIGURE 1: State Party self-assessment annual reporting (SPAR) questionnaire highlighting progress in health service provision capacities in the SEAR during 2018–2020 SPAR indicators that assess capacities specifically related to C.9 Health Service Provision: C.9.1 Case management capacity for IHR relevant hazards; C.9.2 Capacity for infection prevention and control and chemical and radiation decontamination; C.9.3 Access to essential health services 100 90 80 70 60 50 40 30 20 10 0 C.9.1 C.9.2 C.9.3 C.9 Searo Average Global Average Linear(2018)2018 20202019 56 6061 63 65 64 Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 50 Nearly all Member States rapidly enacted policies to implement new cash transfer schemes or augmented existing ones and instituted public financial management reforms to streamline procurement of essential resources and ensure swift cash flows to support emergency measures. Countries like India and Maldives provided fiscal support, including relief packages aimed at helping businesses stay viable, protect jobs and provide aid to low-income households, enabled people to adhere to public health guidance, with the aim of preventing infections. This helped partially to mitigate the strain on a health system struggling to meet the unprecedented demand to deliver high level of health- care services.(79) Operationalizing these policies required countries to mobilize significant resources to finance pandemic response, re-emphasizing the need to strengthen health financing systems as part of a wider goal to building health system resilience.(74) Member States in the Region are continuing to develop systems and policies that combine effective oversight, coalition building, regulation, attention to system- design and accountability for effective management of health emergencies. The decade from 2011 to 2020, witnessed considerable progress across the Region in strengthening health governance and legislation systems. This is reflected in the Regional average score of 70% for the year 2020 which is more than the global average of 67% with respect to implementation status of laws, regulations, policies, administrative requirements and other government instruments to support health emergencies as provided in the IHR annual reporting. (75) Increasing trend of decentralization seen in the Region The Region is becoming increasingly decentralized, following broader public service reforms. While countries such as India and Indonesia have a longer history of a decentralized structure of government others have only started in recent years with partial devolution, as in case of Nepal and Timor-Leste. In India, since health is a state subject, State-level authorities are practically autonomous in managing health systems, infrastructure and human resource requirements, but during emergencies, state health authorities work closely with the Central health system which routinely coordinates with States for select programmes under the National Health Mission, National AIDS Control Organization and others. They have access to national-level funding and unified administrative set-up in addition to SoPs and protocols on reporting and monitoring. The unified approach between the centre and state, especially during emergencies allows a coordinated nation-wide response. In Indonesia, Governors at provincial level have complete authority for health decisions. As seen during the COVID-19 pandemic, the presidential decisions were optional for governors to impose with flexibility to modify at provincial level. Here, it is the National Disaster Management Act (NDMA) that mandates the adherence and following of Central decisions during emergencies. To coordinate preparedness actions and streamline communication channels during emergencies, the hub-hospital concept was introduced by the Ministry of Health and Population (MoHP), Nepal in 2014. Investment in hub-hospital network preparedness in Kathmandu proved beneficial during the 2015 earthquake, leading to strengthening of emergency response capacity of similar networks in mid- and far-western development regions (See Box below). Public and private hospitals, including medical colleges, operated in a coordinated manner for maximum effectiveness in emergencies based on the public private partnership (PPP) model. Participation of staff from private hospitals led to private hospitals developing their disaster preparedness and response plans, expanding the resource pool in emergency response. Investment in hub- hospital network preparedness in Kathmandu proved beneficial during the 2015 earthquake, leading to strengthening of emergency response capacity of similar networks in mid- and far-western development regions. 51Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region To minimize the load of communication in an emergency, the hub-hospital concept was introduced by MoHP in 2014. It demonstrated that efforts and resources spent on preparedness to help health sector response which came into play during the 2015 earthquake. MoHP rolled out the hub-hospital preparedness initiatives for all hub-hospitals in the country. They identified 25 hub-hospitals to coordinate preparedness actions and disseminate directives from MoHP to all health facilities. The public and private hospitals, including medical colleges, operated in a coordinated manner for maximum effectiveness in emergencies based on a PPP model. Further, based on experiences in and around Kathmandu Valley, a project was launched in 2017 to strengthen emergency response capacity of hub-hospital networks in the mid- and far-western development regions of Nepal. The goal was to use the hub-hospital and its network of satellite hospitals to manage mass casualty and severe disease outbreak Strengthening emergency response capacity of hub-hospital networks in Nepal Role of hub-hospitals z Activate Hospital Incident Command System z Establish network with hospitals within the zone z Conduct quick assessment of hospitals z Carry out resource mapping and updating of satellite hospitals z Facilitate training on mass casualty management z Establish and orient early deployment mechanisms z Form early deployment teams z Agree on emergency communication plan and procedures z Agree on reporting format (to hub hospital/HEOC) and focal points z Develop plan for field hospitals Role of satellite hospitals z Establish coordination and communication with hub hospitals z Establish network with hub hospitals z Conduct assessment of hospitals and provide information to hub hospitals z Establish and orient early deployment mechanism within the hospitals z Develop coordination and communication plan with hub hospitals incidents while continuing essential services following emergencies/disasters. Also, to strengthen links between community and hub-hospitals to render effective trauma care and post hospital referral and rehabilitation services. The project was managed by WHO with Danish Red Cross (DRC) and Handicap International as implementing partners and funded by European Commission Humanitarian Aid (ECHO). A total of four hub-hospital assessments using WHO Hospital Safety Index (HSI) tool were conducted in 2019 and seismic assessment reports of individual hub-hospitals developed. (80) Health staff from private hospitals joined a four-day training course on Hospital Preparedness for Emergencies (HOPE) and developed their disaster preparedness and response plans. In addition, Hospital Disaster Preparedness and Response (HDPR) workshops were organized. The hub-hospitals followed up the HOPE and HDPR training with development of Hospital Disaster Preparedness and Response Plans and hub- hospital & satellite network meetings. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 52 Health becomes more than health-care and encourages a whole-of-government approach During the COVID-19 pandemic, countries opted for a whole-of-government approach with a clearly defined, tiered command structure to prepare for and respond to future outbreaks, as well as consolidate all health protection functions under new centralized agencies. For instance, Thailand established a national coordination body, the Centre for COVID-19 Situation Administration (CCSA), led by the Prime Minister, integrating nation-wide response through unified command. Sri Lanka was characterized by strong central government leadership and effective coordination bodies. Multisectoral and multidisciplinary management of health systems. Over the past decade, the Region witnessed more synergistic working relationships between health systems and other sectors for multisectoral and multidisciplinary management of health emergencies. For example, health services are dependent on adequate provision of essential services and support from safe water and sanitation for IPC. Despite large-scale investments in the Water, Sanitation and Hygiene (WASH) sector, there have been challenges in resource-constrained countries. The SEA Region has been focusing on building expertise in health care and WASH sectors, reinforcing the need to create a stronger enabling environment with better policies, processes, and resources at the health-care facility and community level. The SEA Region has been focusing on building expertise in health care and WASH sectors, reinforcing the need to create a stronger enabling environment with better policies, processes, and resources at the health care facility and community level. © W H O /I N ep al 53Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region During the pandemic, many countries faced challenges in ensuring access to safe, quality and efficacious medical products and commodities such as PPE. Due to weak regulations for medical devices, global shortages in supply chain, and proliferation of substandard and falsified PPE made procurement difficult. WHO supported Bangladesh’s National Regulatory Authority, the Directorate General of Drug Administration (DGDA) in establishing a robust system for quality control of PPE. With technical leadership from WHO and under DGDA, an informal technical working group was formed to ensure quality control of PPE. The group comprised of experts from Bangladesh University of Engineering and Technology, International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) and the Japanese inspection firm K2, with financial support from the United States Agency for International Development (USAID) and Japan International Cooperation Agency (JICA). This national consultative process helped develop minimum testing parametres for PPE items (gowns, coveralls, face masks and non-medical masks for community use). Stakeholder consultations were Regulation of PPE during the COVID-19 pandemic in Bangladesh held with importers, local manufacturers, textile testing labs, development partners and relevant government and non-government entities, resulting in a set of minimum testing requirements and list of labs authorized to conduct tests. The test results were used as a basis for issuance of No-objection certificates (NOC) from DGDA for products which complied with specifications. Also Bangladesh’s readymade garment manufacturing industry, which was heavily impacted by COVID-19 (demand for readymade garments in main export markets dropped) was asked to repurpose manufacturing lines to produce PPE. In partnership with the International Finance Corporation (IFC), International Labour Organization (ILO) and the United Nations Population Fund (UNFPA) WHO provided technical support to these manufacturers so they could conform with requirements as mandated by WHO in the Disease Commodity Package for COVID-19. An electronic system was introduced with financial support from USAID in collaboration with WHO to manage distribution of PPE during the pandemic and predict, prevent and monitor stock-out in health facilities. In India, a 2017 assessment of health impact of WASH in rural households revealed that living in areas where WASH measures were implemented and environments had achieved open defecation–free (ODF) status, there was an average saving of US$780 from deaths that were averted, time that was saved, and medical costs that were deferred. Further, the estimated economic return on investment for every dollar invested in sanitation accrued benefits of more than 430%. (81) Building on such examples, the SEA Region strived to have broader multilateral engagement to address chronic public health challenges. Influencing public policy to achieve health gains. The Region acknowledges that national policies in sectors other than health have a major bearing on risk factors for diseases, and health gains can be achieved much more readily by influencing public policies in other sectors (environment, transport, trade, taxation, education, agriculture, urban development, food and energy). This was evident during COVID-19 when Member States worked beyond typical health sectors and developed guidelines and protocols for non-health sectors to supplement existing medical product manufacturing lines. In the early phase of the COVID-19 pandemic, Personal Protective Equipment (PPE) was available in limited supplies in Sri Lanka. Responding to the situation, its Government called on the local apparel industry, women’s groups, Sri Lankan Army and Air Force to support its manufacturing.(82) Likewise, in India, automotive manufacturers were instructed to produce low-cost ventilators and PPE.(83) In a remarkable humanitarian gesture, the MoH in Sri Lanka partnered with the postal department and the police force to deliver medication to patients’ doorsteps in a bid to save lives during the lockdowns. (84) In a remarkable humanitarian gesture, the MoH in Sri Lanka partnered with the postal department and the police force to deliver medication to patients’ doorsteps in a bid to save lives during the lockdowns. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 54 Linkages between public health systems and clinical response capacities. Over the years, regional capacities for early disease detection and control have grown rapidly for good-quality case management and strong surveillance and response systems. However, public health functions, including testing, contact tracing, disease surveillance and non-pharmaceutical public health interventions, often operate separately from health service delivery, though both are critical to pandemic response and to ongoing population health related issues. Emergency care is a critical element of UHC and is an essential part of health service delivery. Well-designed emergency services facilitate timely recognition, treatment management and, when needed, continued treatment of the acutely ill at the appropriate level of the health system. Establishing effective everyday emergency care system in hospitals is also the way for enhancing the capacity of handling mass events. Full-scale simulation exercises including all health sector stakeholders (prehospital care, ambulances, security agencies and public health officials) are the real test of existing preparedness and response plans as shown in the hub-hospitals in Nepal. Attention moved beyond hospital-focused programmes to establish critical linkages between the public health system and clinical response capacities for building more cohesive health systems. In India, the growing network of testing labs offer expanded opportunities to strengthen testing facilities across the country. For early detection and treatment of COVID-19 “high throughput” COVID-19 testing facilities were established at the institutions affiliated to the Indian Council of Medical Research (ICMR). These laboratories have the capacity to test diseases other than coronavirus, such as tests for Hepatitis B and C, HIV, mycobacterium tuberculosis, cytomegalovirus, chlamydia, neisseria and dengue. This will go a long way in strengthening health infrastructure for diagnostics that is strong enough to provide clinical care in a routine post pandemic period. This will also support laboratory based surveillance during large-scale public health emergencies. Key efforts to strengthen health systems in the Region in the recent past include building a committed, well-prepared and responsive health workforce, a fundamental requirement for delivering good-quality health care, especially during emergencies. The average density of doctors, nurses and midwives in the SEA Region has increased from 21.5 to 26.0 per 10 000 population since the decade began – a 21% increase. Nine SEA Region countries are now above the 2006 WHO threshold of 22.8 doctors, nurses and midwives per 10 000 population (1) compared with six in 2014. However, only two countries are above the 2016 revised The All India Institute of Medical Sciences (AIIMS) in New Delhi along with the Centres of Excellence in the States/ UTs bolstered the clinical treatment and critical care of patients in their intensive care units (ICU), thereby managing to keep the case fatality rate (CFR) low in the country. The e-ICU programme is conducted twice a week through video and tele-consultation sessions that mentor and support big COVID-19 hospitals in the States through shared experiences and technical advice from domain experts in clinical management of ICU patients. India’s “e-ICU video consultation programme” adopted by a premier medical institute The Government of India along with efforts of the State/UT governments has ramped up the hospital care infrastructure across the country to ensure that medical care for different categories of positive cases is provided through the Dedicated COVID Care Centre (DCCC), Dedicated COVID Health Centre (DCHC) and Dedicated COVID Hospital (DCH). Continuously expanding hospital infrastructure has helped people recover faster and better from COVID-19. Emergency care is a critical element of UHC and is an essential part of health service delivery. Well-designed emergency services facilitate timely recognition, treatment management and, when needed, continued treatment of the acutely ill at the appropriate level of the health system. 55Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region WHO threshold of 44.5 health workers per 10 000 population that is estimated to be needed for achieving the SDGs. Public health officers and trained field epidemiologists are unable to achieve the target of one trained epidemiologist per 200 000 population.(85,86) Despite their vital role, shortage of trained human resources coupled with uneven geographical distribution pose the biggest challenge to providing health care for the population. In India, Indonesia, Bangladesh and other countries in the Region, ongoing efforts are being made to augment human resources for managing COVID-19 cases. Non-practicing medical and paramedical professionals, retired health professionals, students and others were called in to provide tele-consultation, monitor mild COVID-19, traditional health workers and others were called in to support the COVID-19 repsonse, including, testing, tracing and monitoring mild cases under supervision and providing psycho-social counselling. COVID-19 has underscored the need for strategies to invest in and optimize the existing health workforce to ensure adequate capacity in health facilities to both deliver health services and build health systems that are resilient during emergencies. Need for efficient health information systems. The SEA Asia Region recognizes that a well-functioning health information system is critical for health system resilience as it plays a vital role in public health and health systems management. Timely sharing of case-based data between public health and health care sectors is key to early detection of outbreaks, identification of changes in epidemiological trends and planning of health services. Through the past decade, massive efforts have continued to establish well-functioning systems that ensure production, analysis, dissemination and use of reliable and timely information on health determinants, health system performance and health status. The capacity for health information management remains varied with data collection mechanisms and/or data sources for monitoring and evaluation of health systems which are still evolving in few countries while robust health management information systems (HMIS) exist in others. Sri Lanka was the first country in the world to use the District Health Information Software 2 (DHIS2) for COVID-19 surveillance.(87) The South-East Asia Region recognizes that a well-functioning health information system is critical for health system resilience as it plays a vital role in public health and health systems management. © W H O /I nd on es ia Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 56 Web-based tuberculosis management system, India. The system enabled tracking of all TB patients during the lockdown in 2020, when thousands of low-wage migrants returned home. They would have otherwise missed it had it not been for the digital platform. COVID-19 responses were then integrated with screening and care for NCD using artificial intelligence (AI) to augment the health and wellness centres (HWC) where services are provided.(88,89) Telemedicine platform, India. A doctor-to-doctor tele- medicine platform called eSanjeevani led to massive improvement in access to specialized health services, particularly in rural areas. This National Telemedicine Service crossed a milestone in June 2020 by completing six million consultations through 375 online out patient department (OPD) sessions with over 40 000 patients consulting 1600 doctors and specialists on daily basis, using the innovative digital medium to seek health services. In line with the National Digital Health Mission, eSanjeevani is boosting the digital health ecosystem in the country. Selected examples of successful integration of digital health care Tele-mental health for elders, India. Online technologies supplemented existing social support networks during COVID-19 and helped assist monitoring of health status of older people and improving self-care and self-management options. COVID-19 support lines for seniors, people with disabilities, children and youth offer practical advice and psychological help. Tele- mental health proved a good option for the elderly struggling with mobility issues and societal stigma during intense COVID-19 transmission.(90) Telemedicine services, Indonesia. As an effort to reduce the pressure on the health system, the Government of Indonesia provided free telemedicine services to COVID-19 cases with mild symptoms, which included free online consultations and medicine delivery.(91) Electronic Vaccine Intelligence Network (eVIN), India. The eVIN is being used for the country’s immunization programme as a cloud-based application to track real time stock positioning and supply of routes based on information fed by the ground staff. This was repurposed as the CoWIN Network for COVID-1910. It focused on registration and tracking of incoming travellers from areas with high risk of COVID-19 infection and supported active surveillance until the end of the incubation period. This was later followed up with travellers using the existing health infrastructure. Using digital platforms to maintain essential health services. With increasing internet and mobile connectivity in the Region, Member States are using digital platforms to maintain continuum of health care in communities and to safeguard essential health functions through a public health crisis. A recent survey conducted by HQ to inform a landscape overview of digital contact tracing (DCT) implementation, saw all SEAR countries (except the Democratic People’s Republic of Korea) answering that they had developed/used digital platforms for contact tracing. India, Thailand, Indonesia, and Timore-Leste have used digital proximity tracing tools with success. Aarogya Setu has been powering India’s fight against COVID-19 since its launch on 02 April 2020 and is the most downloaded contact tracing App in the world, with more than 15 crore users and over 160 million Indians through their smart phones. Bluetooth tracing technology is used to analyze and find COVID-19 hotspots and alert the local administration in advance under the ITIHAS+AS patch of the AarogyaSetu App. In late 2020, a digital learning system for knowledge sharing and peer-to-peer engagement for procurement and supply chain (PSM) professionals, was launched in collaboration with the Empower School of Health (GOARN partner), India. The platform breaks with the classical approach of classroom training of staff which is difficult to scale effectively. It is expensive and also challenging to measure its impact. The platform and its community allowed the dissemination of parallel activities for large outreach, (e.g of calls for proposals to improve resilience). 10 Co-WIN system is an end-to-end solution with utilities for the entire public health system from national up to the vaccinator level. A recent survey conducted by HQ to inform a landscape overview of digital contact tracing (DCT) implementation, saw all SEAR countries (except DPRK) answering that they had developed/used digital platforms for contact tracing. 57Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Maintenance of public health logistics. Health logistics and supply chain logistics deliver a variety of functions, including maintenance and distribution of stockpiles and handling and managing of the transport function of infectious substances for laboratory testing. It coordinates operations during outbreaks. COVID-19 stimulated innovations and refocused priorities to support progress towards health systems strengthening, such as adoption and enhanced use of digital technologies, streamlining of procurement systems, increased investment to strengthen disease surveillance and diagnostic capacity of laboratories and greater intersectoral collaboration Components of a Resilient Health System As the SEA Region continues its onward journey of building resilient health systems, based on a strong foundation of primary healthcare, a complex task that encompasses structures and processes, includes having an appropriate legal framework along with robust financial mechanisms. This entails having good governance structures with an enabling environment that link public health services with critical care provisions by a trained workforce and steps up equitable access to essential medical products, vaccines and technologies. There is need to better understand what capacities are required for resilient and responsive health systems in terms of health security, where the intersections between health systems, health security and other sectors are located, and how challenges at these intersections can be overcome and leveraged for multisectoral and multidisciplinary, effective management of health emergencies close to communities. The fragility of health systems has never assumed greater importance than during COVID-19. The loss of life, massive social disruption, disruption to basic health care services across countries has exposed weaknesses in health systems and their resilience. Health system resilience is the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; be informed by lessons learned during the crisis and reorganize if conditions require it. In other words, health systems are resilient if they protect human life and produce good health outcomes for all during a crisis and in its aftermath. In the context of WHO and its Member Countries, in addition to the well recognized building blocks, a resilient health system requires well functioning public health laboratories and health emergency operation centres. Actions towards ensuring Safety of Hospitals A pre-emergency safety assessment of critical health infrastructure providing EHS has been placed on high-priority and recommended for national governments under the Sendai Framework for Disaster Risk Reduction (2015–2030). WHO provided global guidance and tools for evaluators in 2015 for safety assessment of health facilities to be adapted to local country contexts. The International Conference on Implementation of Health Aspects of the Sendai Framework held in 2016 in Bangkok further recommended systematic integration of multi- hazards DRR interventions across all levels of governance and policy frameworks for improving resilience of health systems. After learning lessons from the Indian Ocean Tsunami of 2004 and the Nepal earthquake of 2015, the Regional Office extended technical support to countries to conduct the safety assessment of their key health infrastructure and to take corrective measures for making health systems and service delivery functional in times of emergencies. Some achievements are highlighted below: WHO provided global guidance and tools for evaluators in 2015 for safety assessment of health facilities to be adapted to local country contexts. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 58 Bhutan Seismic vulnerability assessment and contingency plan was developed in three hospitals in Bhutan in 2015. Maldives Equipping most hospitals with solar panels and improving green waste management facilities to integrate climate change adaptation and to build resilience in their health systems. Myanmar With support of the WHO Regional Office for South-East Asia, resources were mobilized, it committed itself to addressing climate change and health. This included ĥ Development of a health-specific component for the adaptation and mitigation plan (2019–2022) ĥ Development of an early warning system for climate-sensitive diseases; and for carrying out an assessment of WASH in health-care facilities in 2019. Nepal 1. Hospital waste management guidelines were updated and endorsed in 2015. 2. The Regional Office supported the development of a mobile and web-enabled application for a multi-hazards safety assessment and hospital preparednessin 2019, called HIS+. This plan was pilot-tested in four hub hospitals, and later integrated into 25 hub-hospital networks after undertaking the capacity- building of its hospital staff. The HIS+ app is adaptable in similar contexts in other countries of the Region. India 1. The National Disaster Management Authority, Government of India released its hospital safety guidelines in February 2016. The institutionalization of hospital safety by a structured training programme for all health cadres started in early 2021. 2. It has also been promoting hybrid-solarization of health facilities in remote areas where regular electric supply is a problem.(92) Sri Lanka 1. They conducted a health facilities safety assessment in drought prone areas from May–July 2017 in five of the most drought-affected and vulnerable districts. The assessment of hospitals led to a recommendation for the development of a contingency plan for drought in the hospital disaster preparedness and response plan.(93) 2. Training of medical officers on the Safe Hospital Initiative was completed in Sri Lanka in 2020. WHO HQ in collaboration with its Regional Offices WHO HQ in collaboration with its Regional Offices, International Hospital Federation, UNDRR and Global Education and Training Institute organized an online “COVID-19 Safe Hospital Webinar Series” from January–April 2021 to discuss the operational readiness of key hospitals along with national strategic plans for “all-hazards” disasters and emergencies. It also prepared for long-term care facilities/services for the COVID-19 pandemic. KEY ACHIVEMENTS TO ENSURE SAFETY OF HOSPITALS 59Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region An efficient public health laboratory system Public health laboratory services are an essential part of a resilient health system. Reliable and timely results from laboratory investigations are critical for decision- making in clinical care, epidemic response, surveillance, prevention and control of diseases. The WHO Regional Office for South-East Asia supports Member States to improve capacity of public health laboratory services for detection of novel, emerging and re-emerging pathogens. In 2011, the WHO Regional Office for South-East Asia and the WHO Regional Office for the Western Pacific (WPRO) developed a national health laboratory policy and plan providing direction for establishing and strengthening national laboratory services.(94) The Five-Year Regional Strategic Plan to Strengthen Public Health Preparedness and Response (2019–2023) also affirmed that a quality-assured and accredited system of laboratories can assist in early detection of health risks and threats. A technical guidance document published in 2018 guided Member States in establishing public health laboratories so that public health professionals could sustain access to services, including in rural and hard- to-reach areas. (95) Peripheral laboratories District laboratories Regional reference laboratories National reference laboratories SUPERVISION AND FEEDBACK REPORTING AND REFERRAL Much effort has gone into improving health laboratory services, with focus on communicable disease control programmes (influenza, poliomyelitis, measles, HIV, tuberculosis and malaria) where funding was available through global health initiatives. The Global influenza surveillance has been conducted through WHO’s Global Influenza Surveillance and Response System (GISRS) since 1952. The GISR and Pandemic Influenza Preparedness (PIP) Framework contributed to building national polymerase chain reaction (PCR) testing capacity and laboratory networking with WHO collaborating centres in the region and key partners such as CDC. However, the connection between laboratory initiatives has not been strong, especially between disease-specific and general public health laboratories. An implication of vertical strengthening of specific laboratories in the region is asymmetric capacity development of laboratory services that need to be considered as an integrated public health laboratory system and not standalone with only parts of the system strengthened to support specific disease control initiatives. Based on the country context, public health laboratories at national and sub- national levels are mandated to perform different yet complementary functions. Adequate infrastructure and human resources are needed along with quality and information management systems that are in line with the national Much effort has gone into improving health laboratory services, with focus on communicable disease control programmes. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 60 integrated public health laboratory system. This will entail mapping, enhancing and establishing of sustainable national laboratory networks with links to other laboratories in related sectors. With respect to laboratory information management systems, digital technology is increasingly providing a platform for integrated national laboratory information management systems for quick turnaround time, linkage of laboratory samples with epidemiological/clinical data and early alerts. The same must be linked to the epidemic intelligence unit for coordinated epidemiological, surveillance, clinical and laboratory activities of public health relevance. National reference centres and mentor institutes need strengthening for essential diagnostics related to virology, bacteriology and molecular techniques. Duwring public health emergencies, these services are made accessible to sub-national levels for diagnostic services, trainings and mentorships. Collaboration with global reference laboratories/ laboratory networks will ensure effective knowledge sharing, technical transfers and referral testing. This comprises international specimen referral systems and regulations for effective pathogen sharing and access to benefits such as diagnostics and vaccines during outbreaks with oterventions of public health implications as per the Nagoya protocol.11 Tackling AMR is a strategic priority of the WHO Thirteenth General Programme of Work 2019–2023 (GPW 13) and a Regional Flagship programme initiated by the Regional Director in 2014. This implies strengthening of microbiology laboratories for AMR surveillance and enhancing management of surveillance data in humans, animals, food and environment for evidence generation. Determination of antimicrobial susceptibility of pathogens is important for the clinical management of patients and to support development of antibiotic policies in hospitals and at national level. One of the best methods of laboratory strengthening is to implement a quality management system (QMS) that complies with requirements of international quality standards. Realizing that Member States will require technical support to strengthen QMS, WHO developed the Laboratory Quality Stepwise Implementation (LQSI)12 tool to provide a stepwise plan to guide medical laboratories towards implementing a quality management system in accordance with requirements of ISO 15189.(96) Member States are in various stages of implementation of QMS. Public health laboratory staff are trained in the use of LQSI tool through regional and international trainings, including training at the KIT Royal Tropical Institute in the Netherlands which is a WHO collaborating centre. Extensive training and application of the tool will remain a regional priority for quality improvement in public health laboratories. Although biosafety and biosecurity awareness and expertise have improved greatly in the past few decades through availability of more effective safety equipment and automated diagnostic technologies, it remains one of the weakest core capacities of Member States, identified by IHR monitoring and evaluation activities. WHO published the 4th edition of the laboratory biosafety manual (LBM4)13 emphasizing a novel evidence- and risk-based approach allowing optimized resource use and sustainable laboratory biosafety and biosecurity policies and practices relevant to their individual circumstances and 11 Nagoya Protocol on access to genetic resources and fair and equitable sharing of benefits arising from utilization to Convention on Biological Diversity, also known as Nagoya Protocol on Access and Benefit Sharing (ABS) is a 2010 supplementary agreement to the 1992 Convention on Biological Diversity (CBD). Adopted on 29 October 2010 in Nagoya, Japan it entered into force on 12 October 2014. As of October 2020 it has been ratified by 128 parties, which includes 127 UN member states and European Union. 12 The LQSI tool is in the form of a website that provides a stepwise plan to guide medical laboratories towards implementing a quality management system in compliance with ISO 15189. 13 LBM has been in broad use at all levels of clinical/public health laboratories and biomedical sectors globally, serving as a defacto global standard with best practices and setting trends in biosafety. It encourages countries to accept/implement basic concepts in biological safety and develop national codes of practice for safe handling of biological agents in laboratories within their geographical borders. Tackling AMR is a strategic priority of the WHO Thirteenth General Programme of Work 2019–2023 (GPW 13) and a Regional Flagship programme initiated by the Regional Director in 2014. 61Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region priorities. This will enable equitable access to clinical and public health laboratory tests and biomedical research opportunities without compromising safety. Five Member States have biosafety Level-3 (BSL-3) laboratories and two are in the process of achieving the same. Most public health laboratories undergo annual inspection/calibration of their biosafety cabinets but inspections remain a challenge as they are resource intensive. The WHO Regional Office for South-East Asia has organized regional laboratory trainings to support Member States in strengthening their capacity to implement biosafety in laboratories. An effective coordination, communication and information management system. During disasters, countries need information management and coordination centres that can bring together the health sector, its partners and other sectoral emergency operation centres to conduct rapid assessments, collect and analyze situational and operational data for decision- making, disseminate those decisions to all concerned agencies and individuals while also maintaining continuity of EHS. Post-disaster needs assessments and AARs will further provide guidance for any future interventions. The WHO Regional Office for South-East Asia has organized regional laboratory trainings to support Member States in strengthening their capacity to implement biosafety in laboratories. To minimize loss due to disasters, the National Emergency Operation Centre (NEOC) was set up in Nepal in 2010 under the Ministry of Home Affairs to coordinate, communicate and disseminate information on emergencies/disasters across the country. Health sector emergency preparedness was identified as a key priority of MoH and MoHP with a need felt for establishing an entity similar to NEOC. In 2012, MoHP set up HEOC on its premises following which HEOC functioned as a high-level operational command centre for MoHP. It was instrumental in coordinating the entire health sector response during the 2015 earthquake. Subsequently, due to federalization, HEOCs were established at all seven provinces acting as health emergency preparedness and response coordination and command centres for provincial governments. These Provincial Health Emergency Operation Centres (PHEOC) were established with financial and technical support from WHO who formally handed over HEOC and PHEOC network to MoHP from 2018 to 2021. The temporary PHEOCs will be converted into permanent PHEOCs once it is decided where to house them. Roles of PHEOC are distinct for three different phases of the disaster management cycle. During the pre-disaster phase, PHEOC is mainly involved in preparedness activities and capacitation at district and palika (municipality) level for contingency plan development, simulation exercises, WHO Hospital Safety Index (HSI) Assessments, training and drills and Emergency Medical Deployment Teams (EMDT) formation and orientation. Subsequently, the HEOC has become the nerve centre for coordinating the health sector response to the Nepal Earthquake 2015; floods and landslide 2017; Kavre-Panchkhal Food Poisoning Case 2018; and US Bangla Air Crash 2018. The PHEOCs helped manage the Bara-Parsa Windstorm 2019, Dengue Outbreak 2019 and the ongoing COVID-19 pandemic, coordinating with hub and satellite hospital networks and Health Emergency Operation Centre (HEOC) Network of Nepal their EMDTs for hospital-level response activities. Recently, the HEOC network developed and strengthened a 24/7 Emergency Care System (ECS) coordinating with WHO for the design and roll-out of a pilot project using WHO- ECS tools and framework in major hospitals providing day-to-day emergency care in each of the country’s seven provinces. During the pandemic, the centre functioned as a communication and hosting hub for weekly health cluster and provincial health directorate and provincial hospital coordination meetings; providing a hotline number and call centre for information, referral and ambulance management; establishing a tele-medicine network; formalizing the orientation and logistics enhancement of hub and satellite hospital network based EMDTs; setting up an emergency information management portal; and developing/ testing of a GIS-enabled digital support system for decision-making around health care risks called OSCAR. These efforts have strengthened the HEOC network as a pre-eminent response coordination, information platform and intervention monitoring centre for health emergencies. © W H O /N ep al

5 C H A P T E R Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 64 © W H O /T ha ila nd 65Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region ROLE OF FRONTLINE HEALTH WORKERS IN EMERGENCIES Frontline health workers hold the key to both the achievement of UHC and public health emergency preparedness and response. COVID-19 illustrated their critical role and also placed them at high risk of infection. Establishing emergency care systems in hospitals with trained staff is important to enhance capacities for handling mass events. WHO Regional Office for South-East Asia Region was the first Region to pass a Regional Committee Resolution on strengthening EMTs. Member States invested in CHWs while Field Epidemiology Training Programmes strengthened surveillance to detect/respond to outbreaks. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 66 T he critical role of frontline health workers in an emergency cannot be underestimated. The Sendai Framework for Disaster Risk Reduction 2015 emphasizes that priority in any emergency is to save lives by bringing “substantial reduction of disaster risk and losses in lives, livelihoods and health.” Reduction in loss of lives and minimizing negative health impacts need an adequate number of trained frontline workers. However, during a disaster, these frontline workers themselves are badly affected, making an existing emergency even more severe. The IHR (2005) has assigned health workforce development as one of its core capacities, especially surge capacity for frontline health workers. Human resources for Health is defined by WHO as “all people engaged in action whose primary intent is to enhance health.” The IHR JEE Indicators measure health workforce development as, “a workforce including physicians, animal health experts/veterinarians, biostatisticians, laboratory scientists and farming/livestock professionals, with an optimal target of one trained field epidemiologist (or equivalent) per 200 000 population. They are expected to systematically cooperate to meet relevant IHR and PVS core competencies.” However, health workforce during an emergency extends beyond these roles, to include physicians, medical assistants, paramedical workers, as well as CHWs who are essential for building community resilience during a disaster, a key goal in the Sendai Framework Statement. © W H O /B an gl ad es h 67Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region The 2019 Health Emergency and Disaster Risk Management Framework (EDRM) by WHO reiterates the need for planning, long-term investment and training of human resources. Various Member States under the WHO Regional Office for SEA have had different approaches to strengthen their human resources for emergencies. During a disaster, local or national capacities are likely to be overwhelmed. Regional EMTs enable EMTs from other countries in the Region to support as surge capacity for a short period of time. A Standby Partnership mechanism in collaboration with international humanitarian organizations is in place and has been tapped into in different health emergency situations, while the roster is managed at WHO HQ. Addressing the need identified by IHR- JEE, most countries have trained field epidemiologists in place thanks to the Regional Field Epidemiology Training Programmes (FETP). Sri Lanka developed a strong and sustainable capacity building programme with a post-graduate diploma course in disaster health management for people across government sectors ensuring they are absorbed in the system after completing the course. (See Box below) The Regional Office has been organizing trainings, inviting participants from MoHs and operational partners to impart knowledge, skills and cross- learning to countries helping them build health emergency capacities. Indeed, the COVID-19 pandemic has pushed a ‘learning while managing response’ for investment in building sector-wide experts to provide surge capacity involving veterinarians, bio-technologists, genetic epidemiologists, virologists, anthropologists, immunologists and social scientists. The Regional Office has been organizing trainings, inviting participants from MoHs and operational partners to impart knowledge, skills and cross- learning to countries helping them build health emergency capacities. A major success of Sri Lanka’s public health emergency management relates to its trained health emergency workforce that meets surge capacity during emergencies. During the period 2006–2009, following the Indian Ocean Tsunami, 2004 and ethnic conflict in the country, a large number of internally displaced persons (IDPs) needed urgent health services. This was a difficult task given the inadequate number of trained health workforce personnel. To address this gap and accordingly strengthen surge capacity, MoH entered into an agreement with the Post Graduate Institute of Medicine of the University of Colombo to develop a course and train medical officers in the health sector on disaster management. A Specialty Board of Study in Health Sector Disaster Management was established and a one-year post-graduate diploma programme launched in 2012. The course is open to the government sector with full paid leave for civil and military cadres. It is a full-time Public Health Disaster Management Diploma in Sri Lanka course that involves classroom training, rotational attachments, field training and a project. Students are attached to the institution and have to conduct risk assessments, develop a preparedness plan and complete a planned drill. Resultantly, every secondary and tertiary hospital in Sri Lanka has a Disaster Preparedness and Response Plan. Once the course is completed, the trainee is assigned to a hospital for six months and every secondary and tertiary hospital is assigned a trainee approximately once in five years when plans are updated and a formal drill performed. Graduates are absorbed back into the system and the diploma is considered for grade promotion. This serves as motivation since it is seen as a career development path. In 2021, the 10th batch was inducted. So far, approximately 200 officers have been trained in health disaster management. The alumni serves as a disaster preparedness network contributing to strengthening health disaster preparedness in Sri Lanka. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 68 Role of CHWs: Giving confidence to the community and providing linkages The CHWs play a critical and unique role in emergencies, having the trust of the communities they work with. During the 2015 earthquake in Nepal, female CHWs played a critical role within the community, providing first-aid and basic medical assistance, mental health support, advise on protecting the public from further health hazards, immunization of displaced persons, and many other roles.(96) There was a strong association between trainings received before the earthquake and their role during the disaster. However, while there have been significant achievements, there are still many gaps. The biggest challenge is the overall shortage of health professionals in the Region. Self-assessment of countries under IHR (SPAR) revealed that only four of 11 countries in the Region scored 80% of their human resource core capacities. This is a critical area that has shown considerable progress, but has a lot more scope for improvement. The COVID-19 pandemic has highlighted the importance of their role as a much-needed bridge when the medical workforce is inadequate to manage the sheer scale of the emergency. Across the Region, CHWs have stepped in during the emergency to provide services well beyond their regular role. This includes assisting with surveillance, contact tracing, detection, referral of cases and testing. In the IHR JEE missions conducted between 2017 and 2019, Indonesia, Sri Lanka and Thailand were assessed as having high score, suggesting regular briefing, training and engagement of social mobilization and community engagement teams, including volunteers who are available and where feedback loops have been possible with the community. However, more efforts are needed to prepare CHWs for working in public health emergencies. Currently programmes in different countries have wide variations, drawing attention to the need to address gaps in core competencies of CHWs. Providing valuable assistance in surveillance and contact tracing Involvement of CHWs in surveillance and screening of symptoms has been important in limiting the spread of COVID-19. Bangladesh, India, Nepal and Thailand conducted screening to detect symptoms. In India, as internal migrants returned home after the lockdowns, Accredited Social Health Activists (ASHAs) who are the local CHWs, screened 30–50 households per day for symptoms. However, with considerable fear and stigma surrounding COVID-19, many familes were reluctant to report if they had been in contact with a suspected case. Since CHWs are trusted by the community, they played an important role in explaining to people the importance of reporting, testing, quarantining, isolating and now vaccinating. They also reassured them of support in case of stigma and linked them to institutions, NGOs and other care facilities to address any other challenges they may have been facing or any other difficulties. This is a role that CHWs have been trained for and have undertaken throughout the region. Maintaining essential health services During COVID-19, while the priority response has been to manage the outbreak, ignoring other health issues is proving to be detrimental too. The COVID-19 pandemic has highlighted the importance of their role as a much-needed bridge when the medical workforce is inadequate to manage the sheer scale of the emergency. 69Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region These include maternal and child health, management of chronic diseases and addressing the needs of vulnerable people within the community. In the early stages of the response, CHWs were unable to continue delivering services either due to the lockdowns or because they were re-directed to working on COVID-19. Programmes put on hold during this period included family planning and sexual and reproductive health, HIV/AIDS management, immunization and child health, malaria and neglected tropical diseases. Routine immunization was also affected although special platforms were created for polio vaccination and CHWs assigned to support relevant populations in several countries like the Maldives with success. Emergency Medical Teams On 07 September 2018, the WHO Regional Committee for SEA adopted a resolution on “Strengthening EMTs in the South-East Asia Region (SEA/RC71/R5)”. This is the first such resolution adopted by any of the six WHO regions. The resolution also established a Regional EMT Working Group comprising representatives of Member States to support implementation of the EMT Initiative. © W H O /C hr is tin e M cN ab In the early stages of the response, CHWs were unable to continue delivering services either due to the lockdowns or because they were re-directed to working on COVID-19. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 70 Following adoption of the resolution, a dedicated team was established within the Emergency Operations Unit of the WHE programme of the Regional Office for SEA. The team developed a dedicated roadmap for each country in collaboration with the respective WHO country office. A comprehensive mapping exercise of EMT capacities for the Region was conducted with over 214 national and international EMTs identified. From 2018–2019, SEARO conducted National EMT Trainings in Thailand, Indonesia, Bangladesh, Bhutan, and DPR Korea, and provided inputs and support to simulation exercises in the Region. These training activities introduced Member States to the EMT Initiative and to how coordination and quality assurance methodologies; mentorship and verification processes; and global principles and standards would be implemented. It provided a platform to familiarize national EMTs with lessons learned from recent emergencies, introducing them to standards and methodologies developed globally. It also built sustainable capacities in national and subnational HEOCs that coordinated the response of EMTs in any type of emergency, utilizing the SEARHEF preparedness stream. Participants to these national training courses were officials from MoH, HEOCs, national EMT staff, collaborating ministries, major hospitals, military, local and international NGOs and UN agencies. To build a sufficient roster of regional EMT coordinators that can be deployed to support Member States, the Regional Office for SEA facilitated an intensive six-day EMT Coordination Cell (EMTCC) training, supported by ASEAN. Participants were trained on EMTCC methodology, taking into account ASEAN SoPs for Regional Standby Arrangements and Coordination of Joint Disaster Relief and Emergency Response Operations (SASOP), and related regional coordination mechanisms. From 2018–2019, SEARO conducted National EMT Trainings in Thailand, Indonesia, Bangladesh, Bhutan and DPR Korea, and provided inputs and support to simulation exercises in the Region. © W H O /B lin k M ed ia – F ab eh a M on ir 71Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Field Epidemiology Training Programmes (FETP) in South-East Asia The duties of field epidemiologists in outbreak investigation are to identify the disease aetiology, risk factors or source of an outbreak, and to contain spread of the disease. In the past decade, countries in the SEA Region have made considerable progress in advancing the epidemiologist workforce the through Field Epidemiology Training Programmes. The FETPs provide critically needed public health and health security services through a mentored, learning-by-doing approach that emphasizes fieldwork and improves effectiveness of the workforce and systems required to provide those services. The FETP intends to: © W H O /M al di ve s Over the past 41 years, the expansion of FETPs across more than 100 countries has increased global capacity for detecting and responding to public health hazards by bringing the world closer to having one trained field epidemiologist per 200 000 population. Bangladesh, India, Indonesia, Myanmar and Thailand Increase number and quality of field epidemiologists in the public health workforce Develop capacity for timely detection, investigation of and response to public health emergencies Improve capacities for collection and effective use of public health data through improved disease surveillance systems Promote use of evidence-based recommendations in public health decision-making and policies. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 72 Table 1: FETP course overview for Member countries in the WHO South-East Asia Region Country FETP Course Established year Cohort / Graduates Affiliated / Host institute Bangladesh Advanced frontline 2013 FETP advanced: total cohort 6, Graduates: 23 FETP B frontline (medical): Total 10 cohort: 169 graduates Institute of Epidemiology, Diseases Control and Research (IEDCR) and National Influenza Centre India Advanced (EIS) 2012 46 National Centre for Disease Control (NCDC) Regional FETP – Basic 1996 293 National Centre for Disease Control (NCDC) Advanced (EIS_NCD) Intermediate (NCD) Advance (EIS) 2001 270 National Institute of Epidemiology (ICMR-NIE) Indonesia Advanced 1982 738 DG DC&E MOH, School of Public Health, University of Indonesia, School of Medicine, Gadjah Mada University Myanmar Intermediate 2008 CEU of Disease Control Division, Department of Health, MOH Sri Lanka Basic (in-service) MoH Thailand Basic Intermediate (FETH & FEMT) Advanced & International (FETP, IFETP & IFETP TOT) 1980 950 Ministry of Public Health run FETPs and offer basic and/or intermediate and/or advanced courses attached to MoH or national institutions. Bhutan, DPR Korea, Maldives, Nepal, Sri Lanka and Timor-Leste are yet to have dedicated FETP courses although their personnel have previously attended FETP trainings in India and Thailand. The FETPs are housed within MoH, national public health institutes and/or academic institutions. Depending on local needs and resources, programmes differ in their personnel structures, cohort sizes and length of training. FETP training follows a three-tier pyramidal model comprising basic, intermediate, and advanced training. Basic-level FETPs, also known as Frontline FETPs (3–6 months), Intermediate-level FETPs (9–12 months) and Advanced training (2 years). FETP fellows from Member States have contributed to disease surveillance system evaluation, outbreak or acute public health investigation, presentation at scientific conferences and publication of peer reviewed articles of epidemiological research studies. FETP graduates are working in various key strategic positions in national disease control programmes for tuberculosis, HIV, leprosy, VBDs, Immunization and as NFPs for IHR. In 2011, a network of FETPs under the ASEAN+3 Field Epidemiology Training Network, was formed to strengthen field epidemiology training capacity in 10 Asian countries in addition to China, Japan and DPRK. (Table 1) FETP graduates are working in various key strategic positions in national disease control programmes for tuberculosis, HIV, leprosy, VBDs, Immunization and as NFPs for IHR. 73Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region FETP Bangladesh played a major role in managing the Nipah outbreak Thailand completes 40 years of FETP and creates a cadre of trained ‘disease detectives’ Countries complete the FETP and contribute to public health situations Nipah encephalitis is a major public health emergency in Bangladesh, which usually breaks out in the winter season. The FETP fellows actively take part in the planning process. They participate in surveillance in endemic areas and carry out awareness campaigns among local population round-the-year. If any signal generates from routine or event-based surveillance system, the National Rapid Response Team (NRRT) is set into motion. The NRRT is closely supported by a FETP fellow in each outbreak investigation and provided technical assistance. FETP fellows conduct epidemiological investigation amongst confirmed, suspected, probable cases, contacts, exposure through interviews with the help of standard questionnaires. They conduct contact tracing; review cases and contact follow-up records. Anthropological survey and verbal autopsy is also conducted. FETP fellows characterize clinical features of Nipah as well. The Thailand FETP was planned and initiated in 1980 with the support of WHO, CDC and MoPH. The programme emphasized learning by doing by helping trainees work on real cases to better understand and apply the knowledge they gained in the classroom. While Thailand pioneered the first FETP model based on CDC’s Epidemic Intelligence Service, it also developed its own innovative elements to enhance programme reach and impact. In 1998, the Thai programme began regional support and training with health officials from neighbouring countries, including Cambodia, China, Indonesia, Laos, Malaysia, Myanmar, and Vietnam. FETP included two to three residents from health ministries outside Thailand in each cohort. So far the programme has trained over 200 Thai and 70 international epidemiologists. Graduates from FETP have become disease detectives at national level. In 2004, the Surveillance and Rapid Response Team (SRRT) was formalized, and since then, trained epidemiologists and public health officers who went on to address numerous infectious disease outbreaks and natural disasters, such as SARS, pandemic influenza, cholera, tsunamis, and avian influenza. Presently, SRRT serves as a major frontline force for health emergency response in Thailand. Recently Thailand celebrated 40 years of FETPs. Few success stories: • A 1981 Rubella outbreak investigation conducted by Dr. Somsak Wattanasri (2nd cohort), led torubella vaccine’s inclusion in the Expanded Programme for Immunization for ASEAN region. • In 1984, Thailand began working on HIV surveillance and four years later, MoPH initiated use of AZT to prevent mother-to-child transmission (MTCT) in Bangkok. The PMTCT-FETP collaboration guided and informed the programme and in 2016, Thailand became the first Asian country to eliminate MTCT of HIV. • In 1992, Thai FETP residents spearheaded Hepatitis B outbreak investigations and research, including vaccine trials. Their efforts led to the launch of Thailand’s successful national Hepatitis B prevention programme. Intensify efforts to overcome shortage of trained health professionals Overall shortage of health professionals in the Region continues to be a major challenge. There is also a longstanding challenge with the distribution and quality of health workforce. The pandemic has shown the critical role frontline health workers play in handling emergencies. Besides increasing number of health workers, preparing them for handling emergencies is essential. Establishing effective everyday emergency care systems in hospitals and clinics with well trained staff is the best preparedness for enhancing the capacity of handling mass events. The FETP concept is relevant, both for human and animal health and linked to the One Health approach. One such model for sustainable, joint capacity development in field epidemiology under a One Health approach has been initiated in Thailand and adopted in other Asian countries. Developing a multi-tier and multisectoral field epidemiology training programme should include appropriate annual continuing education and refresher training courses on basic epidemiology and disease outbreak control measures for human and animal health sectors.

6 C H A P T E R Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 76 © W H O /D er m ot T at lo w 77Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region STRENGTHENING HEALTH EMERGENCY PREPAREDNESS THROUGH INTERNATIONAL HEALTH REGULATIONS (2005) The purpose of IHR (2005) is to prevent, protect, control and provide a public health response to the international spread of disease. In implementing regulations, countries are called upon to assess and strengthen their national public health capacities. Should a public health event occur that may constitute a PHEIC, countries are expected to interact actively with WHO for information sharing, risk assessment and implementation of public health measures. The ability to respond to threats to public health security in a coordinated and transparent way requires well-understood, realistic but flexible plans, policies and procedures that are validated, practiced and evaluated. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 78 P reparedness of public health emergencies through implementation of IHR (2005) has been one of the highest priorities for the WHO SEA Region. The IHR (2005) is an instrument of international law that is legally-binding on 196 countries, including WHO's 194 Member States. It provides an overarching legal framework that defines countries’ rights and obligations in handling public health events and emergencies with potential to cross borders. The IHR (2005) that came into force on 15 June 2007 marked a new era of international cooperation for management of international public health events and emergencies. However, its true implementation and operationalization was tested under real world conditions during the H1N1 pandemic, Ebola, MERS-CoV, Zika and the ongoing COVID-19 pandemic. Since the inception of IHR (2005), countries have been actively engaged in strengthening their national core capacities. They have made marked progress in advancing core capacities as required by IHR, including development of NAPHS. While these capacities have been fully utilized in building response to the COVID-19 pandemic, it has also revealed the need to further improve IHR implementation. © W H O /T im or -L es te © W H O /M ya nm ar 79Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Regional initiatives in IHR (2005) implementation Many initiatives have been implemented in the Region to strengthen IHR capacities. A regional workshop on public health legislation was held in 2013 guiding countries on national laws that support IHR (2005). Main recommendations were to accelerate assessments and revise/adopt relevant legislation, including PoE, providing sufficient legal authority and resources for IHR NFPs and establishing national IHR coordinating bodies. Two regional meetings on IHR Core Capacities at PoE were organized in Sri Lanka (2010) and India (2013). An International Workshop to Review and Strengthen Collaboration for Public Health Preparedness and Response at PoE was organized in India in 2017. These meetings encouraged information sharing on national experiences and discussed regional aspects of implementation of IHR at PoE to determine current strengths and weaknesses and to identify follow-up actions at national and regional level to strengthen core capacities at PoE. The capacity of countries in the SEA Region was further enhanced with the JEE that covered 19 technical areas. So far eight countries have conducted JEE and have since made progress across the region in national legislation, policy and An International Workshop to Review and Strengthen Collaboration for Public Health Preparedness and Response at PoE was organized in India in 2017. © W H O /P lo y Ph ut ph en g Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 80 financing; IHR coordination, communication and advocacy; extent of and access to immunization services; laboratory capacity, surveillance and reporting and risk communication. However, a risk-based approach is needed to bring about further improvement, including emergency preparedness, readiness to deal with unexpected chemical or radio-nuclear emergencies and enhancing biosafety and bio-security in lab networks to curb increasing AMR and prevention and control of disease transmission at PoE. Strengthening these IHR capacities will not only improve national health security but also safeguard travel and trade as also protect economic and social development. Developing capacities for health security demands active and sustained involvement of public and private entities representing health, agriculture, environment, social welfare, finance, security, emergency management, education and transportation. Following IHR assessments, Bhutan, Indonesia, Maldives, Myanmar, Sri Lanka, Thailand and Timor-Leste developed and implemented the NAPHS, while Bangladesh awaits endorsement of the developed NAPHS. National commitment towards health security and the role of high-level leadership are crucial for effective implementation of NAPHS, including securing human resources with multiple skill-sets, intersectoral cooperation and domestic financing. International cooperation and partnerships also support strengthening of national capacity for IHR 2005 through NAPHS. However, the practical operationalization of NAPHS is challenged due to competing priorities between health and non-health sectors, governance, political commitment and sustainable financing. (97) IHR monitoring and evaluation framework A regular cross-sectoral periodic monitoring and evaluation process for NAPHS implementation linking with the IHR Monitoring and Evaluation Framework (IHR-MEF) is underway. (Fig 1) Developing capacities for health security demands active and sustained involvement of public and private entities representing health, agriculture, environment, social welfare, finance, security, emergency management, education and transportation. Fig 1: IHR Monitoring and Evaluation Framework States Parties self-assessment annual reporting (SPAR) After action reviews (AAR) Simulation exercices (SimEx) Voluntary external evaluations Purpose Monitor progress towards implementation of IHR core capacities Assess the functionality of capacities during real events Assess the potential functionality of capacities for non-real events Evaluates objectively IHR contribute to health security Mandate Mandatory Voluntary Voluntary Voluntary Focus Existence of capacities Functionality of capacities Functionality of capacities Existence of capacities Periodicity Annually Within 3 months of specific real events Regularly when required as part of the exercise programme Every 4-5 years Type Quantitative Qualitative Qualitative Qualitative 81Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region The purpose of IHR-MEF is that State Parties can monitor and evaluate implementation of IHR capacities in accordance with requirements for capacity development outlined in IHR (2005). The IHR Review Committee in 2014 recommended that State Parties should urgently strengthen the self-assessment system and annual self-assessment reports and planning processes through multisectoral and multi-stakeholder discussions and implementation of in-depth reviews of disease outbreaks and public health events.(97) It should promote a more evidence-based approach to assess effective core capacities under “real- life” situations. Further, the WHO should conduct regional formal evaluations or meta- evaluations of outbreak reviews, managed by regional offices, to facilitate cross- regional learning and distillation of lessons learned for future IHR programming. With introduction of IHR-MEF, the WHO Regional Office for SEA with Member States promoted and supported IHR monitoring and evaluation to facilitate learning and continuous improvement of country health security systems. The IHR-MEF highlighted the need for multisectoral involvement in assessing and developing plans for strengthening IHR capacities. In order to help countries identify the most critical gaps within their human and animal health systems, JEE was introduced as a voluntary component of the IHR Monitoring and Evaluation Framework. It is a collaborative, multisectoral process to assess country capacities to prevent, detect and rapidly respond to public health risks whether occurring naturally or due to deliberate or accidental events. Findings and recommendations of the JEE are used to identify priority actions to advance implementation of IHR. This is in addition to informing development and updation of NAPHS with emphasis on country ownership, intersectoral coordination and strategic partnerships. Establishing the SEARO Knowledge Network for IHR NFP Successful implementation of IHR in the Region needs continuous capacity building of NFPs to improve their competencies, learning from peers, new emergencies and being updated from other regions and global developments. Consequently, the SEARO Knowledge Network for IHR NFP was established in 2019. The WHO also utilizes the platform to update training resources, including innovative tools and online learning courses that focus on NFPs and stakeholders. In addition, the guidance documents, country best practices and resource materials for addressing emerging public health issues are part of the online “Knowledge repository” to be accessed by NFPs and technical experts in the region. Pandemic Influenza Preparedness Framework (PIP) and IHR (2005) The PIP Framework, which marks a decade in 2021, is a landmark, innovative public health arrangement to increase global preparedness to respond to pandemic influenza. It came into being due to initiatives by Indonesia and the Regional Office for SEA which played a critical role in the development of this Framework. It brings together Member States, industry, other key stakeholders and WHO. The two key objectives of the PIP are to: Improve sharing of influenza viruses with potential to cause pandemics among humans Achieve more predictable, efficient, and equitable access to benefits arising from sharing of viruses, notably vaccines and antiviral medicines In order to help countries identify the most critical gaps within their human and animal health systems, JEE was introduced as a voluntary component of the IHR Monitoring and Evaluation Framework. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 82 The framework includes a benefit-sharing mechanism, called the Partnership Contribution (PC) which is collected as an annual cash contribution from the influenza vaccine, diagnostic and pharmaceutical manufacturers that use the WHO Global Influenza Surveillance and Response System (GISRS). Implementation of PIP PC is guided by two implementation plans, namely PIP PC High-Level Implementation Plan (2014-17) (HLIP I) and PIP PC High-Level Implementation Plan (2018–2023) (HLIP II). These plans guide the use of PIP PC funds towards capacity building to improve global pandemic preparedness over its dedicated time period. Their development and implementation relies on engaging a broad range of stakeholders including PIP Advisory Group (AG), GISRS, industry and civil society organizations. For capacity building, activities are implemented according to six outputs in the High-Level Implementation Plan (HLIP) II 2018–2023 – Laboratory & Surveillance (L&S), Burden of Disease (BOD), Regulatory Capacity Building (REG), Risk Communications and Community Engagement (RCCE), Planning for Deployment (DEP) and Influenza Pandemic Preparedness Planning (IPPP). Country-level and regional support is provided through biennial workplans with stepwise approach to improving capacities over the six-year implementation period. These outputs directly relate to core capacities outlined in IHR. Evidence from HLIP I (2014–2017) has shown five IHR core capacities that have been positively impacted by PIP investments – including surveillance, response, preparedness, risk communications, and laboratory core capacities. Additionally, PIP priority countries have reported greater improvement in their capacities compared to other countries. This shows the collateral and broader benefit of working on PIP as a corollary for broader health security capacity- building. The investment in preparedness capacities due to PIP helped tackle several challenges during the COVID-19 pandemic. The GISRS network of laboratories was used for SARS-CoV-2 virus sharing and data reporting format supported by PIP. Other enhanced capacities, such as epidemiology and RCCE were also used during the pandemic. Notable achievements in recent years • With the introduction of the self-assessment tool for IHR (2005) in 2010, Member States actively engaged in assessment, barring few who reported delays. The WHO SEA Region maintained 100% reporting status of SPAR from 2016 to 2020, although many Member States were occupied with COVID-19 response during 2020. • The WHO Regional Office for SEA through country offices encouraged multisectoral involvement in responding to the SPAR questionnaire, quality assessment of IHR capacities, utilization of SPAR data for heath sector planning and strengthening of IHR capacities. • Eight Member States have conducted voluntary JEE exercises and developed their NAPHS based on identified gaps and recommendations of JEE. • Few Member States reported multistakeholder coordination during JEE and NAPHS process as well as follow-up implementation of NAPHS activities to strengthen their response to COVID-19. • IHR oversight committee in countries like Thailand and Sri Lanka facilitated positive governance over NAPHS implementation process. • After holding the Regional Training Workshop on AAR & Simulation Exercises (SimEx) in 2019, many Member States conducted AAR and SimEx to test their functional assessment. • With support from WHO, Bhutan conducted an airport simulation exercise to test readiness of airport health authority on handling sick passengers on an incoming flight. They received feedback from the government who found the exercise helpful for mounting their COVID-19 preparedness and response. • Following temporary recommendations from the emergency committee on COVID-19, WHO supported five countries (Thailand, Indonesia, Bangladesh India and Bhutan) to conduct national and subnational IARs to retrieve lessons learned from the pandemic by identifying strengths and challenges as well as priority actions to strengthen their health security systems. • Indonesia was one of the first countries to conduct IAR and incorporate recommendations to country strategic preparedness and response plans. With implementation of recommendations, periodic follow-up on operations was also carried out. The investment in preparedness capacities due to PIP helped tackle several challenges during the COVID-19 pandemic. 83Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Future direction for assessment of IHR core capacities should take place in parallel with health system capacity on UHC for more accurate analysis of capacities at national and subnational levels. More experience sharing and reporting by countries needed States Parties should strive to integrate core capacities for emergency preparedness, surveillance and response within the broader health system and essential public health functions, to ensure health systems are sufficiently resilient to function effectively during pandemics and other health emergencies. (99) The COVID-19 pandemic has emphasized the need to strengthen tools and processes for assessing, monitoring and reporting on core capacities of IHR (2005), taking into account lessons learned from the current pandemic, including functional assessments, to allow for accurate analysis and dynamic adaptation of capacities at national and subnational levels. More efforts are needed in sharing experiences and reporting on AAR and SimEx. Future direction for assessment of IHR core capacities should take place in parallel with health system capacity on UHC for more accurate analysis of capacities at national and subnational levels. To support full implementation of IHR (2005), health-related SDGs and triple billion targets, Universal Health and Preparedness Review (UHPR) is proposed as a periodic peer-review to compliment existing IHR-MEF. Sustainable financing for implementation of NAPHS and advocacy is needed. Based on COVID-19 response, Member States along with partners must be encouraged to invest in health emergency preparedness in line with the Five-Year Regional Strategic Plan to Strengthen Public Health Preparedness and Response. © W H O /B hu ta n Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 84 Influenza planning is guided by influenza control plan of MoPH and supported by the Central Hygiene and Anti-Epidemic Institute (CHAEI) responsible for surveillance and management of infectious diseases and central medicine warehouse responsible for provision and management of supplies. (Fig 2) National pandemic influenza preparedness plan includes making of policy, planning, budgeting, multisectoral collaboration and international support. Various stakeholders support managers responsible for national pandemic influenza planning. Technical support is provided by CHAEI for influenza patient survey, report, collection and transport of influenza sample, reorientation, supervision, monitoring and laboratory diagnosis. Their activities, including supervision, result of treatment and system management is duly reported to NIP of MoPH. They are responsible for providing technical guidance, training, reorientation and supportive supervision for province, city and counties. Through the year, DPRK sustained its influenza surveillance, with reports from influenza- like illness (ILI) and severe acute respiratory infections (SARI) sites collected regularly despite pandemic precautions. An integrated approach to surveillance saw such suspected ILI or SARI cases undergo testing for COVID-19. The country now regularly reports epidemiological and laboratory data to FluNet and FluMart. In 2020 there was a steady decline in number of ILI and SARI cases as infection control measures were practised widely, including hand hygiene. In 2019, the National Influenza Plan for retaining active NIC status was developed by MoPH, with WHO’s assistance. In addition, the country’s National PIP, which was developed in 2018, was reviewed by WHO HQ and Regional Office and the contents finalized. Recognizing the need for strengthened laboratory capacity for prompt and accurate diagnosis of seasonal influenza in the country and for better epidemic preparedness, a “twining” initiative was started between the National Influenza Laboratory and the Hong Kong Supra National Reference Laboratory. With PIP funds, several officials and laboratory experts were trained in China, Hong Kong Special Administrative Region on the external quality assurance programme for isolation and confirmation of influenza. Importantly, PIP surveillance and reporting mechanisms were streamlined, enabling reports from ILI and SARI sites to be collected regularly. In late 2018, for the first time, ILI and SARI surveillance EPI data from November was shared with FluNet to supplement laboratory data. The country is now regularly reporting epidemiological and laboratory data to Flu Net and FluMart. (Fig 3, 4, 5) Influenza surveillance in DPRK FIGURE 2. Influenza surveillance in DPRK Provision and management of supplies Training and disease control and management Provincial medicine warehouse City/county medicine warehouse PHAEI Ri (town, district dong) hospital, clinics City/county public health bureau City/county HAEI Central medicine warehouse MoPH (State hygiene control board) Provincial public health bureau CHAEI 85Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Numbers of SARI Cases-DPR Korrea 2019-20 900 811 594 520 450 48 110 6458 71 89 115 122 56 21 12 11 333 3 800 700 600 500 400 300 200 100 0 4 6 19 1313 10 6 J. .. F. .. M ... M ... A ... Ju n J. .. S. .. A ... O ... N ... D ... J. .. A ...J. .. A ... M ...F. .. O ... N ...S. .. J. .. M ... D ... J. .. F. .. M ... Numbers of ILI cases- DPR Korea 2019-20 8000 5922 4838 3599 2845 1283 2566 3936 5783 6751 1082 0 583 536 372 172 130 98 56 39 37 51 69 103 128 190 158 116 7000 6000 5000 4000 3000 2000 1000 Ja n Fe b M ar A p r M ay Ju n Ju l A u g Se p O ct N o v D ec M ar -2 1 Ju n -2 1 N o v- 20 Se p -2 0 Ju l- 20 M ay -2 0 M ar ch 20 Ju n 20 Fe b -2 1 D ec -2 0 O ct -2 0 A u g -2 0 Ju n -2 0 A p ri l 2 0 811 455 Fe b 2 0 FIGURE 3. Number of ILI cases DPR Korea 2019–2020 FIGURE 4. Number of SARI cases DPR Korea 2019–2020 FIGURE 5. Number of specimens positive for influenza by subtype and % positive, 2018–2020 A/H1N1pm09 A/H1N1 A/H3N2 A/H5N1 A (Unsubtyped) B Yamagata B Victoria B (Unsubtyped) % Positive 350 300 250 200 150 100 50 0 70 60 50 40 30 20 10 0 % p os it iv e N um be r of p os it iv e 1 36189 45275 402314 4931 1 136 3618 189 94527 275 54023 2314 1431 31 20192018 2020

7 C H A P T E R Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 88 © W H O /C hr is to ph er B la ck 89Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region ONE HEALTH: ZOONOTIC THREATS AND FOOD SAFETY COLLABORATION BETWEEN HUMAN AND ANIMAL HEALTH AUTHORITIES The FAO-OIE-WHO have been working together post the avian influenza crisis in the Asia-Pacific region to provide strong leadership to endorse the One Health concept and promote interagency and intersectoral collaboration. The programme on highly pathogenic emerging diseases in Asia (2010– 2014) led to establishment of a regional tripartite coordination mechanism in the region to support collaboration between animal and human health sectors. The remit of this mechanism has expanded to include other priority One Health challenges, such as AMR and food safety. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 90 T he Asia-Pacific region has been recognized as a hotspot for emerging infectious diseases, 75% of which are of zoonotic origin. A human outbreak of avian influenza A(H5N1), detected in 1997 in Hong Kong Special Administrative Region, China, was the first recognized instance in which a highly pathogenic avian influenza virus had been transmitted to humans and resulted in serious illness. Re-emergence of the virus in 2003–2004 in Asian countries compelled national authorities to work together at the human–animal interface and highlighted the absence of guidance for establishing a functional coordination mechanism between public health and animal health sectors. Considering the acute need to promote close collaboration between sectors for managing the avian influenza crisis, as well as prevention and control of priority zoonoses, the WHO Regional Offices for South-East Asia and Western Pacific – in collaboration with FAO, Regional Office for Asia and the Pacific and OIE Regional Representation for Asia – developed “Zoonotic diseases: a guide” to establishing collaboration between animal and human health sectors at the country level in 2008. The guide focused on four components: Surveillance and information sharing Coordinated response Risk reduction Collaborative research 1 2 3 4 © W H O 91Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region In 2019, considering the evolving situation and growing need for a global standardized guidance document for taking a multidisciplinary One Health approach, WHO, in collaboration with FAO, OIE and international partners, further developed the guide, ‘Taking a multisectoral One Health approach: a tripartite guide to addressing zoonotic diseases in countries’.(100) Asia-Pacific Strategy for Emerging Diseases (APSED) Considering the devastating impact of emerging infectious diseases such as SARS, avian influenza and the weak public health system in Asian countries, the Regional Offices for the Western Pacific and South-East Asia came up with a bi-regional strategy called the APSED in 2006. The APSED serves as a roadmap to ensure all countries in the Asia Pacific region are able to fulfil their IHR (2005) requirements, thus ensuring regional health security and contributing towards this global goal. Results from the evaluation of APSED implementation conducted in 2015 confirmed that Member States viewed APSED as an important and relevant strategy for implementing IHR (2005). As a result, in 2015, the Technical Advisory Group on the Asia Pacific Strategy for Emerging Diseases (APSED TAG) recommended that WHO develop a new strategy for the Asia Pacific region. This new strategic framework, the Asia Pacific Strategy for Emerging Diseases and Public Health Emergencies (APSED III), reflects the “all-hazards approach”. (101) Zoonoses control is one of the priority areas under APSED which has been instrumental in establishing coordination and collaboration between human health and animal health sectors, including partnership with FAO and OIE. A generic guide to establishing collaboration between human health and animal health sectors at the country level was published under APSED which was endorsed as a tripartite document that served as a basic document to develop the global Tripartite Zoonoses Guide in 2019. (102) Zoonoses control is one of the priority areas under APSED which has been instrumental in establishing coordination and collaboration between human health and animal health sectors, including partnership with FAO and OIE. ‘One Health’ is an approach adopted for designing and implementing programmes, policies, legislation and research in which multiple sectors communicate and work together to achieve better public health outcomes. The areas of work in which the approach is relevant include food safety, control of zoonoses and AMR. Close human– animal relationships, intensification of agricultural practices to feed the increasing human population, deforestation, human encroachment on natural habitats, indiscriminate use of antimicrobial agents and climate change have contributed to the emergence and re-emergence of new pathogens and public health emergencies. Many of the same microbes infect animals and humans, as they share the ecosystems they live in. Efforts by just one sector do not provide Understanding One Health and its relevance optimal solutions to prevent or eliminate the problem. Information on influenza viruses circulating in animals is crucial to selection of viruses for human vaccines for potential influenza pandemics. Drug-resistant microbes can be transmitted between animals and humans through direct contact between animals and humans or through contaminated food. To effectively contain it, a well-coordinated approach in humans and animals is required. Also, to effectively detect, respond to and prevent outbreaks of zoonoses and food safety issues, epidemiological data and laboratory information must be shared across sectors. Government officials, researchers and workers at local, national, regional and global levels should implement joint responses to health threats. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 92 Highly Pathogenic Emerging Diseases (HPED) programme To advocate and operationalize One Health in Asia, the European Commission funded a Highly Pathogenic Emerging Diseases (HPED) programme through FAO, OIE and WHO during 2010–2014. WHO Regional Office for SEA coordinated the public health component of the HPED programme with ASEAN and SAARC Secretariats and partner agencies. A functional tripartite coordination mechanism was established and tripartite workshops organized jointly to advocate One Health and to use the regional platform to share good practices to operationalize One Health in the country. So far, eight tripartite workshops have been organized on rotational basis between 2010 and 2019. WHO Regional Office for SEA hosted its tripartite workshop in 2013 in Kathmandu and the Asia-Pacific workshop on zoonotic influenza surveillance, prevention and control in 2015 in Thimphu, in collaboration with FAO and OIE. This was attended by human health and animal health officials, leading experts and WHO collaborating centres. To advocate for greater awareness and importance of zoonotic diseases, a series of risk communication materials on priority zoonoses of regional importance (Anthrax, avian influenza, rabies, brucellosis, toxoplasmosis, Nipah, CCHF) were developed and disseminated. There was a request from health policy-makers in India, to produce a practical guide written in simple language providing succinct information on recognition, prevention and control of emerging infectious diseases. In response to this request, a brief guide was published to assist policy- makers and public health professionals during emergencies. It included Ebola, SARS-CoV, CCHF, Chikungunya, Nipah virus and other potential zoonoses and the time has proved its importance and relevance. A regional media workshop on EID and zoonoses was also organized in Kathmandu to make media aware of Ebola, MERS-CoV, avian influenza and Zika. Establishment of the Asia-Pacific One Health Coordination Group FAO, OIE and WHO established the Asia-Pacific One Health Coordination Group in 2020. Four working groups were identified for operationalization of One Health on zoonotic influenza, rabies, AMR and food safety. The tripartite © W H O /S EA RO A functional tripartite coordination mechanism was established and tripartite workshops organized jointly to advocate One Health and to use the regional platform to share good practices to operationalize One Health in the country. 93Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Thailand was the first country to confirm a COVID-19 case outside Wuhan. What could have aggravated into a major public health crisis was curtailed thanks to its two-decade-long research on coronaviruses and bats? They provided valuable evidence that shaped the country’s response to the outbreak and provided valuable insights to the rest of the world. Immediately after taking the patient’s swab from the back of the nose on 08 January 2020, it was sent for analysis at the Thai Red Cross Emerging Infectious Diseases-Health Science Centre, Chulalongkorn University, which is also the WHO collaborating centre for Research and Training on Viral Zoonoses. The institute confirmed the presence of a coronavirus by a real-time RT-PCR test which picked up genetic material from the coronavirus before obtaining a partial genetic sequence. (103) Distinctive features of the novel coronavirus found in the patient did not match what was publicly available, even though its genes were similar to sequences of coronavirus strains found in horseshoe bats in China. The specimen was sent to the Health Science Centre and National Institute of Health (NIH) where both laboratories performed testing at the same time, using different methods. Microbiologists at the National Influenza Centre at the NIH conducted extensive validation of the virus’s DNA using Metagenomic Sequencing by Next-Generation platform, referring to publicly available whole-genome sequencing data for 30 000 base pairs. On 11 January, the full genetic sequence of coronavirus circulating in Wuhan was released. When Thailand’s Thailand’s research on horseshoe bats provided early clues to the novel Coronavirus National Influenza Centre compared it with the full genetic sequence of the virus that was isolated from the Wuhan traveller, they found a 100% match between viruses, confirming the first case of COVID-19 on 13 January. The NIH further developed oligonucleotide primers and probes for detection of 2019-nCoV selected from regions of the virus nucleocapsid (N) gene. The panel highlighted high-standard capacities and practices of national laboratories. Further, in testing for novel coronavirus, Thailand followed WHO’s COVID-19 technical guidance: Lab testing for 2019-nCoV. Also, its “One Lab One Province-24-hour reporting policy” which mandates having at least one lab in each of the country’s 77 provinces to test for novel coronavirus -- provided timely results helping quickly identify local hotspots of infection. From 01 January to 26 June 2020, a total of 603 657 samples were tested using the RT-PCR method by laboratories under MoPH and those at military and police hospitals, universities and private hospitals. Soon 203 labs were certified to confirm COVID-19 test results using the RT-PCR method. Nationwide contact tracing was undertaken with a sentinel surveillance system involving over 100 000 nasopharyngeal swab and saliva sampling tests, targeting at-risk people including health workers, prison inmates, migrant workers, messengers and drivers. Going forward, the country will be highly vigilant in detecting any traces of new local transmission. secretariat is established at the regional level and coordinated by FAO in the first two years. The secretariat will be coordinated by OIE and WHO on a rotational basis. The establishment of the Coordination Group acknowledged the importance of close coordination and communication across sectors and committed partners. Member States and regional organizations will strengthen coordinated efforts to fight existing and emerging health threats. COVID-19, MERS-CoV, zoonotic influenza and rabies are examples of diseases which cross species and infect humans, causing many infections and deaths at a global level, while incurring serious socio-economic implications. In 2018, under the tripartite group, a workshop was held to accelerate Prevention and Control of Neglected Foodborne Parasitic Zoonosis in select Asian Countries in 2018 in Luang Prabang, Lao PDR. Human health, animal health and food safety officials from Member States discussed foodborne parasitic zoonoses and agreed on applying the One Health approach, taking into account their country context and priorities. Given the lack of public and professional awareness on parasitic zoonoses, the tripartite finalized fact sheets on six priority foodborne parasitic zoonoses in Asia and made them available online. Human health, animal health and food safety officials from Member States discussed foodborne parasitic zoonoses and agreed on applying the One Health approach. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 94 Elimination of human rabies Rabies is one of the priority zoonotic diseases selected by Member States for operationalization of One Health and tripartite collaboration. ASEAN countries were supported by WHO to develop the ‘ASEAN Rabies Elimination Strategy’ in 2016 and a series of meetings/workshops were organized under the tripartite banner to support regional cooperation and capacity building. Two Rabies meetings for SAARC countries were organized by WHO SEARO in Colombo in 2015 and OIE in Kathmandu in 2019. All SAARC countries completed the stepwise approach for Rabies elimination (SARE) exercise14 helping these countries develop their NAP for Rabies elimination. In 2012 WHO Regional Office for SEA developed the ‘Regional Strategic Framework for elimination of human rabies transmitted by dogs’ while Bangladesh, Bhutan, India, Indonesia, Myanmar and Sri Lanka developed their National Strategy for Rabies Control and subsequent Elimination.(104) The cost-effective intradermal rabies vaccination was pioneered by Queen Saovabha Memorial Institute (QMSI) in Bangkok in 1986. WHO’s Regional Office for SEA promoted the use of intradermal rabies vaccination under the Regional Strategic Framework. Five contries from the SEA Region adapted to improve accessibility, affordability and availability of modern rabies vaccine. The SEA Region is one of the WHO regions after the Regional Office for Europe that phased out production and use of nerve-tissue rabies vaccine under the SAARC initiative in 2015. There are four WHO collaborating centres related to rabies control, namely the Queen Saovabha Memorial Institute (QMSI), Bangkok; Chulalongkorn University, 14 The Stepwise Approach towards Rabies Elimination (SARE) has been developed as a template that countries may use to develop activities and measure progress towards a national programme and strategy for sustainable rabies prevention, control and eventually elimination. • WHO CC for Rabies Diagnostics (NIMHANS Bangalore) organized laboratory diagnosis training for Bangladesh, India, Myanmar, Nepal and Sri Lanka; Regional Office provided a lateral flow test for field diagnosis of rabies and rabies conjugates to Bangladesh, Bhutan, India, Myanmar, Sri Lanka. • NIMHANS Bangalore provided rabies antibody titration and referral services to India and Nepal and the Regional Office supplied a standard rabies serum for antibody titration as it is not commercially available. • Rabies vaccine and rabies immunoglobulin was arranged on emergency basis for Indonesia, Myanmar and Nepal. • National Guidelines on human rabies prophylaxis was developed and revised as per new WHO recommendations in 2017 for Bangladesh, India, Myanmar, Nepal and Sri Lanka. Support for rabies control provided by WHO Regional Office for SEA • WHO standard guidelines on Rabies prophylaxis did not address region specific issues such as milk or meat consumption or saliva contact for post-exposure prophylaxis and the Regional Office came up with ‘FAQ on Rabies’ which was translated in Arabic, Bangla, Burmese, Dari, Dzongkha, Indonesian Bahasa, Kannad, Khmer, Nepali, Parsi, Pastu, Urdu, and Vietnamese. • Regional Office supported GAVI-funded assessment of rabies accessibility, delivery and distribution of human rabies vaccine in Bangladesh, Bhutan, India, Nepal and Sri Lanka. A meeting of African and Asian countries was organized in Kathmandu in April 2018 to disseminate outcome of GAVI sponsored rabies vaccine assessment activity. • Regional Office has been working with animal welfare organizations (Mission Rabies), Global Alliance for Rabies Control and partners to provide technical support and technology transfer to rabies endemic countries. Five countries from the SEA Region adapted to improve accessibility, affordability and availability of modern rabies vaccine. 95Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 15 The MAT is the gold standard for sero-diagnosis of leptospirosis because of its unsurpassed diagnostic specificity. Bangkok; National Centre for Disease Control (NCDC), Delhi; and National Institute of Mental Health and Neuroscience (NIMHANS), Bangalore. A WHO Expert Consultation on Rabies was organized in Bangkok in 2017 by WHO HQ for the first-time outside Geneva, leading to the publication of the 2nd WHO Expert Consultation Report. India and Thailand were represented in the Strategic Advisory Group of Experts (SAGE) Working Group on rabies vaccines and rabies immunoglobulins that functioned from 2016 until 2018. Strengthening leptospirosis surveillance, prevention and control Leptospirosis is a worldwide spirochete zoonotic infection prevalent in the Asia Pacific region. The disease occurs mainly where humans or other animals come in contact with the urine of infected animals or a urine-polluted environment. A series of trainings on laboratory diagnosis of leptospirosis were organized at the WHO collaborating center on leptospirosis, Port Blair, India to provide hands-on training for laboratory professionals from Bhutan, India, Indonesia, Myanmar, Nepal and Sri Lanka, followed by in-country training to establish microscopic agglutination test (MAT) for leptospirosis diagnosis15 and distribution of diagnostic test kits and reagents for MAT. As a result, these countries are now reporting laboratory confirmed leptospirosis. WHO Regional Office for SEA in coordination with the Global Leptospirosis Environmental Action Network (GLEAN) supported organization of a National workshop on leptospirosis cum GLEAN meeting in Colombo (Sri Lanka) in 2016, Kathmandu (Nepal) in 2018 and Bali (Indonesia) in 2019. The workshop provided a platform for integration of innovative ideas and approaches and sharing of success stories for prediction, detection, prevention and response to leptospirosis. The Regional Office has been supporting participation of leptospirosis endemic countries, namely Bangladesh, Bhutan, India, Indonesia, Myanmar, Sri Lanka and Thailand. Regional Framework for Action on Food Safety Food safety is a major element of public health and any breach may result in considerable burden of foodborne diseases. Access to safe food is closely related to SDGs such as good health and well-being, elimination of poverty, gender equality, water and sanitation, sustainable production and consumption, and climate change. Food safety is a shared responsibility and demands multisectoral and multidimensional collaboration of all stakeholders – governments, food business operators, consumers and academics across the food chain. The Framework for Action on Food Safety in WHO South-East Asia Region (Fig 1) was finalized via consultation with Member States and endorsed by National Food Safety Authorities in 2019. The Framework identifies key activities prioritized for delivery over 2020–2025 and is grounded on lessons learnt from the Regional Food Safety Strategy 2014–2018. The framework is based on a situation analysis of the food control system in Member States and progress made through implementation of the Regional Food Safety Strategy, including the WHO 13th General Programme of Work, Codex Strategic Plan (2020–25) and recommendations of WHO/FAO/African Union (AU) Global Food Safety Conference. The Framework underlines the strategy to safeguard consumer health by strengthening food control and foodborne disease surveillance systems. This Framework will provide guidance to competent authorities involved in food safety across the food chain, and to authorities involved in food safety emergencies, preparedness and response in Member States. The Regional Office has been supporting participation of leptospirosis endemic countries, namely Bangladesh, Bhutan, India, Indonesia, Myanmar, Sri Lanka and Thailand. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 96 Establishment of a functional National Codex Committee (NCC) is critical to facilitate Codex activities at country level, but most countries have weak NCCs. The main role of the committee Is to set and adopt international standards at country level. The WHO Regional Office for SEA supported Codex advocacy and INFOSAN workshops in Bhutan, DPR Korea, Maldives, Myanmar, Nepal and Timor- Leste. Support was also provided for participation in the Codex Committee for Asia meeting in New Delhi, India in 2016 and Goa, also in India in 2019 helping countries understand the importance of Codex in food safety and trade and to encourage them to actively participate in the Codex standard setting process. WHO also facilitated Timor-Leste to became the 188th Member of the Codex Alimentarius Commission. Codex Trust Fund The Codex Trust Fund (CTF) has been established by FAO and WHO to support Member States to build strong, solid and sustainable national capacities to engage in Codex. WHO Regional Office for SEA, in coordination with FAORAP facilitated the submission of a joint project proposal submitted by India, Bhutan, and Nepal. The group application was challenging as food safety authorities of these three countries had to come together and agree on a common agenda. WHO HQ and the Regional Office provided technical support and demonstrated leadership and convenorship facilitating the complex project development and its implementation. It was the first multi-country project approved by the CTF at global level and the first CTF project in Asia. This project will further strengthen national Codex activities in participating countries through inter-country codex collaborations, including common positions in Codex standard setting process. By helping to create a sustainable platform for the national food safety authorities in three countries to work together, and with a strong sense of ownership in this effort by all three countries, this project will potentially have a high impact for a relatively low cost. A side event on CTF was organized at the Codex Committee for Asia meeting in Goa in September 2019 to help Member States to better understand the application process and expectations of successful applications. Bhutan, India and Nepal were provided the opportunity to share experiences in preparing group applications, recommendations for better outcomes in the application process and progress in implementing the group project. Myanmar submitted a group application on behalf of Cambodia, Lao PDR and Myanmar facilitated by FAO and WHO. An additional activity was organized under CTF in 2019, namely an intercountry workshop on food safety risk analysis on chemical contaminants in food. Indonesia was the first country in the Asia-Pacific region to use FAO/WHO tool for the National Food Control Systems assessment. It had a clear objective to improve its national food control system (NFCS), consistent with international principles and concepts established by Codex. In 2017, the Indonesian government partnered FAO and WHO in assessing its NFCS, bringing together 11 ministries and institutions including academia. Local and international consultants were mobilized to conduct situation analysis and facilitate an interactive and participatory assessment with national stakeholders FAO/WHO support Indonesia’s assessment of its National Food Control System identifying priority actions in developing a multi-year strategic plan for implementation. The plan helped mobilize domestic funding and improve intersectoral coordination. As follow-up to the recommendations, a risk profiling and categorization training was organized with an FAO supported consultant and within a WHO supported national activity in 2018–2019. It was a cost-effective, resource efficient and country-focused multistakeholder activity supported jointly by FAO and WHO and in line with WHO’s GPW 13. By helping to create a sustainable platform for the national food safety authorities in three countries to work together, and with a strong sense of ownership in this effort by all three countries, this project will potentially have a high impact for a relatively low cost. 97Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Strenthening food control system Protecting, promoting and supporting consumer health Food business comply with food safety legislation and standards COMPONENT 1 Policy and legal framework COMPONENT 2 Control management COMPONENT 3 Risk-based inspection COMPONENT 4 Data and information to support evidence COMPONENT 5 National laboratory system COMPONENT 6 Preparedness and response to food safety emergencies COMPONENT 7 Food safety communication and education Functional coordination mechanism for food control is established at national and subnational levels Stategic goal strenghen country capacity in managing food safety risk through integrated food control programmes across the food chain Fig 1: Vision, mission and strategic goal of framework for action Food safety incidents and emergencies are well man-aged Reduced incidence of foodborne illnesses Legal provision for consumer health protection Reliable food safety information available for consumer health protection Increased food safety awareness among consumers Safe and healthy food for all individuals Strengthen food control systems to protect, promote and suppport consumer health Vision Mission Expected outcomes Food control measures are conducted based on scientific evidence/risk based Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 98 Assessment of foodborne disease surveillance and response Between 2015 and 2019, eight out of 11 Member States completed the assessment of their foodborne disease surveillance including the development of an action plan for strengthening the surveillance system. Follow-up action for implementation of priority activities was taken up by respective WHO Country Offices. The assessment was important for advocacy at the policy level while objectively evaluating food safety under SPAR and JEE under IHR (2005). Assessment of foodborne disease surveillance and response, including the development of a priority action plan through a validation workshop in Myanmar in 2016 was timely as it provided input for the JEE mission under IHR in Myanmar. It was important to promote mutual understanding, coordination and collaboration among the Central Epidemiology Unit (CEU), Myanmar Food and Drug Administration (FDA) and the National Health Laboratory. INFOSAN in action The International Food Safety Authorities Network (INFOSAN) is a global voluntary network of national authorities with a role in food safety, coordinated by a joint FAO/WHO Secretariat. INFOSAN is an important communication mechanism for exchanging information on food safety incidents and emergencies related to internationally traded foods, facilitating rapid access to relevant information. INFOSAN alerts on country-specific events were shared with the Member States. ‘INFOSAN in Asia’ food safety meetings were jointly supported by WHO Regional Offices for South-East Asia and the Western Pacific in Hong Kong in 2016 and Seoul in 2018. These simulation exercises on coordination and response to multicountry food safety events were attended by NFPs and INFOSAN Emergency Contact Points from SEA (Bhutan, India, Indonesia, Myanmar, Nepal, Thailand and Sri Lanka) and Western Pacific regions. The results of the simulation exercise were shared and steps for strengthening communication between NFP and INFOSAN ECP were identified. Carving out an agenda for the future In the event of any future outbreaks of new emerging zoonoses at the human-animal interface (e.g., avian influenza viruses, Zika virus, Nipah virus, leptospirosis and CCHF), it will be necessary to have the requisite expertise and coordination with different agencies involved in outbreak response. Close INFOSAN is an important communication mechanism for exchanging information on food safety incidents and emergencies related to internationally traded foods, facilitating rapid access to relevant information. © W H O 99Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region The WHO Global Salmonella Surveillance (GSS) is a consortium of medical and veterinary epidemiologists and laboratory experts on foodborne diseases which brings together leading experts from European Centers for Disease Control, US Food and Drug Administration, Public Health Agency of Canada, Japan and WHO CCs such as US CDC Atlanta, Technical University of Denmark and University of Utrecht. The Chulalongkorn University, Faculty of Veterinary Science had been the WHO GSS Regional Center of Excellence in Asia for decades. They trained epidemiologists and microbiologists from countries of the Asia-Pacific region on foodborne disease surveillance and laboratory investigation including on networking. They also provided countries with tools to obtain an estimate of the national burden of foodborne diseases. GSS was reorganized with expanded scope of activity and renamed Global Foodborne Infection Network (GFN) in 2009. GFN fosters intersectoral and multi- disciplinary collaboration to detect, control and prevent foodborne and other enteric infections through International training on foodborne disease surveillance and laboratory investigation in SEA Region in collaboration with Global Foodborne Infections Network (GFN) trainings, workshops and networking. It has three training modules on epidemiology, laboratory and joint epidemiology and laboratory. Capacity building activity was institutionalized in other countries as foodborne disease surveillance tends to be neglected and burden of foodborne diseases remains unknown due to lack of data and information. WHO Regional Office for SEA facilitated discussion with ICMR to host GFN training at the National Institute of Cholera and Enteric Diseases, Kolkata (WHO CC) as part of celebrating centennial anniversary of ICMR. It was agreed to contextualize the laboratory training module focusing on foodborne pathogens primarily on V. cholerae, Salmonella and Shigella. WHO GFN coordinated the funding of the training programme and mobilization of GFN members to facilitate trainings organized in two batches. Since then, NICED is actively involved in organizing training and EQA with European Centers of Excellence on antigenic characterization of foodborne pathogens. India has now dentified training institutions for such training in four of its regions. coordination must be seen between national authorities and WHO, FAO, OIE and international partners. The One Health coordination mechanism, therefore, needs strengthening. While coordination may be good during a crisis period, more efforts are needed to prepare for future crises. In other words, Member States should be encouraged to invest more on preparedness. WHO in collaboration with FAO and OIE must help the Member States to establish a functional One Health Secretariat to promote joint planning and implementation of priority zoonoses, surveillance and response of zoonotic events using tripartite operational tools. With the potential threat of new emerging zoonoses, Member States have high expectations for technical support from WHO and the tripartite. Greater technical expertise will be needed on zoonoses and veterinary public health along with practical experience to deal with intersectoral coordination and collaboration. WHO Regional Office for SEA helped the Member States to establish a functional National Codex Committee and to conduct an assessment of foodborne disease surveillance and response during 2015–2019. Priority actions have been identified in eight countries in the Region with WHO supporting the establishment of a foodborne disease surveillance system, capacity building for joint outbreak investigation and development of food safety emergency preparedness plans. More efforts are needed to make better use of WHO CCs for technical advice, capacity building and referral services. Member States have recognized the need for a One Health approach to address zoonoses, zoonotic influenza, food safety and AMR but there are challenges to establishing a functional coordination mechanism for operationalization of One Health. More financial resources and collaboration with international partners to support the One Health initiative at the country level will be needed to strengthen interactions at the human and animal health interface. Greater technical expertise will be needed on zoonoses and veterinary public health along with practical experience to deal with intersectoral coordination and collaboration.

8 C H A P T E R Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 102 © W H O /B an gl ad es h 103Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region HARNESSING DIGITAL TECHNOLOGIES TO SHARPEN PUBLIC HEALTH RESPONSE TO COVID-19 HUMAN AND ANIMAL HEALTH AUTHORITIES Digital technologies have been added to public-health innovations at the heart of disease-prevention-and- containment strategies. The first WHO guidelines on digital health interventions for health-system strengthening were published in 2019. COVID-19 provided an opportunity for health care’s digital revolution with the accelerated expansion of telehealth, telemedicine and digital health apps. Tools were launched with online triage, symptoms checking, video visits and remote monitoring besides conducting epidemiological surveillance studies. Artificial intelligence-based tools are helping diagnose cases and identify at-risk patients with good results. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 104 D igital health initiatives have proven to amplify socioeconomic inequalities while reducing disparities in access to health care. Digital technology involves the use of the internet and mobile phones. In 2019, as many as 204 billion apps were downloaded and as of January 2020, more than 3.8 billion people were actively using social media to connect with each other and to access information. (104) During the ongoing COVID-19 pandemic, while the world continued to rely on classic public-health measures, a wide range of digital technology was harnessed to augment and enhance traditional public-health strategies. These ensured speed, accuracy, convenience and optimum utilization of resources. All countries are required by IHR (2005) to have the core capabilities to ensure national preparedness for infectious hazards with the potential to spread internationally. Research and development of new methods and technologies to strengthen these core capacities often occur during outbreaks when innovation is welcomed and regarded as an absolute necessity. During the outbreak of SARS in 2003, Hong Kong identified clusters of diseases through the use of electronic data systems. WHO handed out free mobile phones to health workers in Papua New Guinea to enhance surveillance during a cholera outbreak in 2009. During Ebola outbreaks in West Africa in 2014–2016, mobile phone data was used to model travel patterns and hand-held sequencing devices permitted more effective contact tracing and a better understanding of the dynamics surrounding the outbreaks. © W H O /B hu ta n 105Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region In 2018, the Seventy-First World Health Assembly passed a Resolution WHA71.7 on Digital Health, recognizing the value of digital technologies in advancing UHC and SDGs. On 22 March 2020, WHA released a draft of its global strategy on digital health for 2020–2024 and on 08 April, the European Union called for a pan-European approach on the use of apps and mobile data for COVID-19. (106) While countries are still trying to get a grip over the high transmissibility and uptake of COVID-19 vaccines, Government coordinated efforts are focusing on containment and mitigation, with varying degrees of success. Countries that have maintained low COVID-19 per-capita mortality have demonstrated the use of strategies for early surveillance, testing, contact tracing and strict quarantine. The scale of coordination and data management required for effective implementation of these strategies have relied largely on their adoption of digital technology and successful integration of the same into policy and health care. Adoption of digital technologies to manage different aspects of COVID-19 The spread of COVID-19 across the world and its recurrence has seen governments and health organizations scrambling to contain the spread of coronavirus. This has spawned the use of digital technologies including artificial intelligence (AI) for greater accuracy, efficiency and access to improve health and health care delivery. Even though current AI-based technologies are far from replicating human intelligence, they have shown good results in tracking the outbreak, diagnosing patients, disinfecting areas and speeding up the search for a cure for the virus. Big data is providing opportunities for performing modelling studies of viral activity and guiding individual country health care policy-makers to enhance preparation for the outbreak. AI and deep learning can enhance the detection and diagnosis of COVID-19. The need to provide access to accurate and low- cost tests for the diagnosis of COVID-19 remains a challenge with the need for Countries that have maintained low COVID-19 per-capita mortality have demonstrated the use of strategies for early surveillance, testing, contact tracing and strict quarantine. The guiding principles aim at orienting the Global Strategy as well as the appropriate and sustainable adoption of digital health in countries. Advocate successful digital health initatives that require a unified strategy. The development of sustainable health systems that promote universal access to care can benefit with appropriate use of digital technologies. To deliver its potential, digital health initiatives must be guided by a robust strategy that integrates financial, organizational, human and technological resources. History shows that ill-coordinated initiatives lead to vertical or stand-alone ICT solutions, that although well-intended can result in information fragmentation and poor delivery of care. Global strategy on digital health 2020–2024 Guiding Principles Acknowledge that the digital health adoption process is a country’s decision. The Global Strategy acknowledges that each country owns its digital health strategy and that along their journey towards UHC and person- centered care, countries will adopt digital health in a way that best suits their vision, health needs, available resources and core values. Promote appropriate use of digital technologies. The strategy will promote the ethical and appropriate uses of digital technologies, to bridge the digital divide and ensure no one is left behind. It will promote ways to protect populations against misuse of information, cyber-attacks, fraud, extorsion, fake news, racism and other human-rights violations. It will stimulate adoption of health technology assessment methods that support and encourage effective innovation. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 106 expansion of public health laboratory capacity. While these issues are being addressed satisfactorily with new technologies that are being piloted, other digital communication platforms are supporting adherence to social-distancing measures on a wider scale. Video conferencing is now a norm, allowing people to work and attend classes from home and online services are supporting mental health and digital platforms are enabling community-mobilization efforts by providing ways to assist those in need. The unprecedented humanitarian and economic needs presented by COVID-19 are driving the development and adoption of new digital technologies at scale and speed. The potential of digital technologies to support epidemiological intelligence with online datasets is being recognized as identification of cases and clusters of infections improve, contact tracing expedited, travel patterns monitored during the lockdown and public-health messaging-enabled at scale. Digital technologies cannot operate in isolation and need to be integrated into existing public healthcare systems. Technology platforms to raise awareness and enhance public education Digital technology is enhancing public-health education and communication. Many countries are using WhatsApp (owned by Facebook) to allow the public to receive accurate information about COVID-19 and government initiatives. © W H O /S EA RO Video conferencing is now a norm, allowing people to work and attend classes from home and online services are supporting mental health and digital platforms are enabling community- mobilization efforts by providing ways to assist those in need. 107Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Multiple social-media platforms (Facebook and Twitter) are currently used by health care agencies to provide ‘real-time’ updates and clarify uncertainties with different target groups. Facial recognition companies are going a step further by adopting thermal imaging–enabled facial recognition to identify those with an elevated temperature at strategic screening points. Google Trends and Maps, Twitter and Instagram feeds and Tiktok videos are being used by the CDC and WHO to track the progress of the disease and to spread awareness on the need to adopt public health and social measures to protect and safeguard themselves from infection. Caller tunes have been used by several health ministries, to raise awareness and promote health campaigns encouraging people to “Stay Home, Stay Safe.” (107) Greater efficiencies in mapping early diagnosis and spread Data visualization is an important tool for exploring and communicating findings. It plays a critical role in epidemic/pandemic time series analysis and forecasting. Many tools, including dashboards, have been developed extensively during the pandemic by WHO HQ and the SEA Region, collating real-time public- health data, including confirmed cases, deaths and testing figures, to keep the public informed and to support policy-makers in refining interventions. COVID-19 dashboards typically focus on time-series charts and geographic maps, ranging from region-level statistics to case-level coordinated data. Several dashboards show wider responses to the pandemic, such as clinical trials, policy and economic interventions and responses to social-distancing directives. Few dashboards include data on contact tracing and community surveillance from apps to gauge their effectiveness. Challenges with the quality and consistency of data collection remain a concern. Lack of official standards and inconsistencies in government reporting of statistics across countries make global comparisons difficult. Up-to-date and accurate offline statistics from governments are also not always accessible. Novel visualization approaches are emerging, such as the NextStrain open repository, which presents viral sequence data to create a global map of the spread of infection. This is enabled by open sharing of data and is based on open-source code. Such speed in sharing such data has not been witnessed in previous global outbreaks. Digital health technology can facilitate pandemic strategy and response in ways that are difficult to achieve manually. Countries like South Korea have integrated digital technology into government coordinated containment and mitigation processes— including surveillance, testing, contact tracing and strict quarantine, all of which are associated with the early flattening of their incidence curves. Big data and AI have helped facilitate COVID-19 preparedness and tracking of people and control spread of infection, in several countries. Tools such as migration maps, which use mobile phones, mobile payment applications and social media to collect real-time data on the location of people, allowed Chinese authorities to track the movement of those who had visited the Wuhan market, the pandemic’s epicentre. With this data, machine learning models were developed to forecast regional transmission dynamics of SARS-CoV-2 and to guide border checks and surveillance. Early and rapid case identification is crucial during a pandemic for the isolation of cases and appropriate contacts to reduce the onward spread and understand key risks and modes of transmission. Digital technologies have supplemented clinical and laboratory notification, through the use of symptom-based case WHO created a repository of >5000 peer- reviewed and curated research articles on varied aspects, including epidemiology, clinical features, diagnosis, treatment, social factors, and economics. By applying the AI technique of Natural Language Processing, it is now possible to discover the direct effects of COVID-19 and also the systematic implications such as the anticipated rise in TB and cancer mortality due to the non-availability of drugs during the export lockdown as highlighted by the models. This is a good example where users understand, synthesize, and take pre- emptive action with the available peer-reviewed evidence on COVID-19. (108) Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 108 identification and widespread access to community testing and self-testing, and with automation and acceleration of reporting to public-health databases. Although this approach is suitable for symptomatic people, widespread testing of people and populations, as well as contact tracing, has a crucial role in case identification, as an estimated 80% of COVID-19 cases are mild or asymptomatic. Sensors, including thermal imaging cameras and infrared sensors, are being deployed to identify potential cases on the basis of febrile symptoms. Technology adds a new dimension to routine testing There has been increasing interest in decentralized, digitally connected rapid diagnostic tests to widen access to testing, increase capacity and ease the strain on health care systems and diagnostic laboratories. Several point-of- care COVID-19 PCR tests are in development, although their use is still limited to health care settings. Drive-through testing facilities and self-swab kits have widened access to testing. There are inherent delays between sampling, sending samples to centralized labs, waiting for results and follow-up. By contrast, point-of-care rapid diagnostic antibody tests can be implemented in home/ community/ social-care settings and provide results within minutes. Linking to smart phones with automatic readout through the use of image processing and machine-learning methods can allow mass testing to be linked with geospatial and patient information that is rapidly reported to both clinical and public-health systems to speed up results. To work effectively, there has to be a standardization and integration of data into electronic patient records. Machine- learning algorithms are being developed for case identification by automated differentiation of COVID-19 from community-acquired pneumonia through the use of hospital chest scans by computerized tomography. (109) Machinelearning algorithms are being developed for case identification by automated differentiation of COVID-19 from community-acquired pneumonia through the use of hospital chest scans by computerized tomography. © W H O /M al di ve s 109Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Digital epidemiological surveillance A core public-health function of outbreak management is understanding infection transmission in time, place and person and identifying risk factors for the disease to guide effective interventions. A range of digital data sources are being used to enhance and interpret key epidemiological data gathered by public-health authorities for COVID-19. Established population surveillance systems mostly rely on health-related data from laboratories, notifications of cases diagnosed by clinicians and syndromic surveillance networks. Syndromic surveillance networks are based on reports of clinical symptoms, such as ‘influenza-like illness’, rather than a laboratory diagnosis, from the hospital and selected sentinel primary and secondary healthcare facilities, which agree to provide regular surveillance data of all cases. These sources, however, ultimately miss cases in which health care is not sought. Identifying undetected cases would help elucidate the magnitude and characteristics of the outbreak and reduce onward transmission. In the past two decades, data from online news sites, news-aggregation services, social networks, web searches and participatory longitudinal community cohorts have aimed to fill this gap. Data-aggregation systems, including ProMED- mail, GPHIN, HealthMap and EIOS, which use natural language processing and machine learning to process and filter online data, have been developed to provide epidemiological insight. These data sources are increasingly being integrated into the formal surveillance landscape with an expanded role to play in the area of COVID-19 surveillance. The EPI-BRAIN platform16, spearheaded by WHO and the World Economic Forum, brings together diverse datasets for infectious-disease emergency preparedness and response, including environmental and meteorological data. Several systems have claimed detection of early disease reports for COVID-19, through the use of crowd-sourced data and news reports, before WHO released a statement about the outbreak. There is interest in using online data to estimate the true community spread of infectious diseases. Preliminary work on the epidemiological analysis of COVID-19-related social-media content has been reported and is being presently studied. Crowdsourcing systems used to elucidate the true burden of disease are also supporting syndromic surveillance. The COVID-19 symptom-tracker app has been downloaded by millions of people in the UK and USA and is feeding into national surveillance. While rapid and informative, these systems can suffer from selection bias, over-interpretation of findings and lack of integration with official national surveillance that report established surveillance metrics. (110) The Internet of Things (IoT) is another sophisticated tool that has provided a platform that allows public-health agencies access to data for monitoring the pandemic. For example, ‘Worldometer’ provides a real-time update on the actual number of people known to have COVID-19 worldwide, including daily new cases of the disease, disease distribution by countries and severity of the disease. (111) The Johns Hopkins University’s Center for Systems Science and Engineering developed a real-time tracking map for following cases of COVID-19 across the world, using the data collected from CDC, WHO, the European Center for Disease Prevention and Control, China CDC and Chinese website DXY, which aggregated data from China’s National Health Commission and the China CDC. 16 The EPI-BRAIN is an innovative global platform that allows experts in data and public health to analyze large datasets for emergency preparedness and response. range of digital data sources are being used to enhance and interpret key epidemiological data gathered by public-health authorities for COVID-19. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 110 Use of mobile apps for contact tracing Mobile applications or mApps have been used primarily for contact tracing – tracking persons and notifying authorities, using Bluetooth. Notable examples include TraceTogether (Singapore), CovidWatch (USA), PeduliLindungi (Indonesia), Kwarantana Dommowa (Poland), HaMagen (Israel). In India, there is Aarogya Setu that can detect other nearby smartphones that also have the app installed. It can then figure out the risk of infection based on sophisticated parameters if any of these contacts are tested positive. The basis of this calculation – which is done using Bluetooth, algorithms, and AI – is the smartphone user’s interaction with others with ePass features being added. Already more than 100 million or 10 crores of downloads have occurred. In countries that are using technology for contact tracing effectively, the first step will be to install tracking apps on phones. Robots and Drones are being used globally to combat COVID 19. Drone technology makes it possible to scan through a crowd of people and detect the person who may be in need of urgent medical attention or, transporting medical samples and disinfecting using aerial sprays. Drones are being deployed to warn people against breaching restrictions of the national lockdown and to ensure there is no supply disruption of essential requirements. Video games in recent times use High-performance computing (HPC) that helps turn a large amount of data into visual pictures. Graphics processing unit (GPU) accelerates these graphic tasks to render images. These GPUs are usually attached toCentral processing unit (CPU) of the computer to create video display. This technology helps in (virus) protein three-dimensional (3D) reconstruction and similarity searching. The use of GPUs has helped immensely in reconstructing the structure of the coronavirus protein. Digital contact tracing automates tracing on a scale and speed not easily replicable without digital tools. It reduces reliance on human recall, particularly in densely populated areas with mobile populations. In the COVID-19 pandemic, digital contact-tracing apps have been developed for use in several countries. These apps rely on approaches and technologies not previously tried on this scale and are controversial in terms of privacy. Evaluating their accuracy and effectiveness is essential. Managing the technology fuelled ‘infodemic’ Public-health organizations and technology companies are stepping up efforts to mitigate the spread of misinformation and to prioritize trusted news sites. For example, Google’s SOS alert intervention prioritizes the WHO and other trusted sources at the top of search results. There are few reports about the impact of these interventions and difficulties in defining misinformation. A United Nations study found that 86% of Member States had placed COVID-19 information on national websites by early April 2020, and many of them used text messaging to reach populations who did not have access to the internet. Chat-bots (software applications used to conduct an online chat) provided information to reduce the burden on non-emergency health advice call centres while clinical practice got transformed by the rapid adoption of remote health-service delivery, including telemedicine, especially in primary care. (112) Role of telehealth in providing care for COVID and non-COVID illnesses The pandemic has provided an opportunity for health care’s digital revolution with an unprecedented, accelerated expansion of telehealth, telemedicine and Digital contact tracing automates tracing on a scale and speed not easily replicable without digital tools. 111Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region other digital health tools. Several tools have been developed and launched at a national and international forum to face the emergency, including tools to perform online triage, symptoms checking, video visits and remote monitoring and to conduct local and national epidemiological surveillance studies. Telehealth is transforming health care delivery during the pandemic on several fronts, most notably with stay-at-home outpatient care; initial COVID-19 hospital surge; post-pandemic recovery; digitized hospital processes; knowledge management for medical professionals; telemedicine; and new IT initiatives for health care services. (113) AI-based tools have been developed to diagnose cases of COVID-19 and to identify patients at risk. Most of these technologies have been endorsed by medical societies such as the American Medical Association and the American Academy of Family Physicians which launched specific guidelines about their use. The growth in telemedicine services and digital health technologies could not have occurred without important telehealth regulatory changes that have occurred in some countries aimed at promoting their use to face the emergency, such as deregulating the use of video conferencing and video chat systems to carry out video visits and reducing payment parity between telehealth and in-clinic care. To decide whether or not to continue using these tools post the pandemic, it would be useful to perform validation and efficacy studies of these tools to study their implications on the doctor-patient relationship, to understand if the new features can be integrated with other technological tools already in use, and if they can improve clinical practice and quality of care. Virtual clinics have been set up in practically all the counties under the WHO SEA Region using tele-medicine consultations with imaging data (chest X-ray and/or CT of the thorax) uploaded from peripheral sites and interpreted remotely. This ensures that patients continue to receive standard clinical care while reducing Virtual clinics have been set up in practically all the counties under the WHO SEA Region using tele-medicine consultations with imaging data (chest X-ray and/or CT of the thorax) uploaded from peripheral sites and interpreted remotely. © W H O /M al di ve s Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 112 • Taiwan initiated health checks for airline travellers from Wuhan, integrating data from immigration records with its centralized, real-time national health insurance database. This integration allowed health facilities to access patients’ travel histories and identify individuals for SARS-CoV-2 testing and tracking. Despite its proximity to Wuhan, China and its susceptibility to COVID-19, the efficient use of big data helped Taiwan in keeping its number of cases and deaths low. • Swedish Health Services, a USA-based health care organization developed a platform for health care workers to report real-time data on volumes of patients with COVID-19, PPE, staffing, ventilator usage and other resource information. This was shared across its hospitals to track the status of facilities, allocate health care resources, and increase hospital bed capacity. • China used free, web-based and cloud-based tools to screen and direct individuals to appropriate resources helping reduce levels of panic and improve management of COVID-19. • Iceland launched widespread testing of asymptomatic individuals. Using mobile technology they collected data on patient-reported symptoms and combined the data with other datasets such as clinical and genomic sequencing data to reveal information about the pathology and spread of the virus. The approach added to the knowledge base regarding prevalence and transmission of asymptomatic COVID-19 helping Iceland maintain the highest per-capita testing rate and lowest per-capita COVID-19 mortality rate. Global examples for screening for infection and contact tracing (115) • South Korea implemented tools for aggressive contact tracing, using security camera footage, facial recognition technology, bank card records and global positioning system data from vehicles and mobile phones to provide real-time data and detailed timelines of people’s travel. They received emergency text alerts about new COVID-19 cases and people who could have been in contact with infected individuals and were instructed thereafter to report to testing centres and self-isolate. By identifying and isolating infections early, the country maintained among the lowest per-capita mortality rates in the world. • Singapore launched a mobile phone application to exchange short-distance Bluetooth signals when individuals were in proximity to each other. The application recorded these encounters and stored them in their respective mobile phones for 21 days. If the person was diagnosed with COVID-19, the MoH accessed the data to identify contacts of the infected person. • Germany launched a smartwatch application that collected pulse, temperature and sleep pattern data to screen for signs of viral illness. Data from the application was presented in an interactive online map where authorities could assess the likelihood of COVID-19 incidence across the country. With widespread testing and digital health interventions, Germany maintained a low per-capita mortality rate, despite a high prevalence of cases. physical crowding in hospital premises. For other key hospital activities (research and education), virtual e-learning platforms are being explored to eliminate physical meetings. The utilization of AI-based triage systems is also alleviating the clinical load of physicians. An online medical ‘chat bot’ helps patients recognize early symptoms, educate people on the importance of hand hygiene and refer them for medical treatment should symptoms worsen. A chatbot or chat-robot is a software application (often powered by AI) to carry out online chat conversation through text or text-to-speech, instead of conversing directly with a live human being. Few noteworthy chat-bots are from CDC, WHO, Google, and IBM Watson. Additionally, phone-based software that detects and records patients’ data (daily temperature and symptoms) may prevent unnecessary hospital consultations for patients with mild flu-like symptoms. This data was developed into AI algorithms to detect COVID-19. Third, many hospitals in China are collaborating with blockchain companies and pharmacies to deliver patients’ medication to their doorstep. Through the use of blockchain, hospitals can ensure timely delivery of medications with accurate tracking. (114) 113Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Quarantine and self-isolation With digital technology, quarantine is being implemented in individuals exposed to or infected with the virus, with less strict restrictions imposed on other citizens. China’s quick response (QR) code system, in which individuals are required to fill out a symptom survey and record their temperature, allows authorities to monitor health and control movements. The QR code serves as a COVID-19 health status certificate and travel pass, with colour codes representing low, medium, and high risk. Individuals with green codes are permitted to travel unrestricted, whereas those with red codes are required to self-isolate for 14 days. China also uses AI-powered surveillance cameras, drone-borne cameras, and portable digital recorders to monitor and restrict the gathering of people in public. Here, AI is facilitating rapid diagnosis and risk prediction of COVID-19 as also detect COVID-19 pneumonia cases. The technology processes CT images in seconds, differentiating COVID-19 from other lung diseases and speeding up the diagnostic process substantially. COVID- Net, an open-source deep convolutional neural network design available to clinicians across the globe, can quickly detect COVID-19 cases from other lung diseases on chest x-rays. Machine learning algorithms are predicting the likelihood of developing acute respiratory distress syndrome and critical illness among infected patients. These prediction models can guide clinical decision-making and resource allocation, identifying regions and hospitals in need of critical care resources and medical supplies. Virtual care platforms, using video conferencing and digital monitoring, have been used worldwide to deliver remote health care to patients as a means of reducing their exposure to SARS-CoV-2 in health care institutions at a scale that is becoming increasingly unfeasible or at least challenging by traditional means. The evidence base on the benefits and harms of digital health Increased interest in digital health has also been illustrated by implementations rolled out in the absence of a careful examination of the evidence base on benefits and harms. The enthusiasm for digital health has also driven a proliferation of short-lived implementation and an overwhelming diversity of digital tools, with a limited understanding of their impact on health systems and people’s well-being. This concern was highlighted in the consensus statement of the WHO Bellagio eHealth Evaluation Group, which opened by stating: “To improve health and reduce health inequalities, rigorous evaluation of eHealth is necessary to generate evidence and promote the appropriate integration and use of technologies.” While recognizing the innovative role those digital technologies can play in strengthening the health system, there is an equally important need to evaluate their contributing effects and ensure that such investments do not inappropriately divert resources from alternative, non-digital approaches. This is highlighted in WHO guideline: Recommendations on digital interventions for health system strengthening. (116) The COVID-19 pandemic has driven many countries to develop digital tools and mobile phone applications, many lacking functionally and often released prematurely without proper testing. While digital health may improve efficiency with updated surveillance data, effective sharing of information can save travel time. There are also few factors that may decrease acceptability. Many people will have privacy concerns for sharing information through potentially unsafe digital platforms. Individuals who are dealing with health conditions that are often stigmatized or very personal (e.g., HIV, TB, family planning and abortion care) worry that their confidential health information will be disclosed or their identity traced due to their participation in targeted communication programmes. Virtual care platforms, using video conferencing and digital monitoring, have been used worldwide to deliver remote health care to patients Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 114 Fig 1. Classification of digital health interventions Digital health interventions contributing to health system strengthening WHO guidelines provide insight on how emerging digital health interventions are contributing to health system improvements. (Fig 1) They provide an overview of areas that can improve the management and service delivery of health systems. The figure below identifies areas from a client, health worker, health manager and data services perspective. Disruptions of electricity and poor connectivity need to be addressed since they often characterize disaster and public health crisis areas. Re-establishing mobile phone services after disasters is another high priority where telecommunication companies can play an important role. What does the future hold? The future of public health is increasingly turning towards technology-based tools and digital innovations. Key stakeholders in the digital field, such as technology companies could be long-term partners in preparedness rather Key: solid orange outline = full inclusion; dotted orange outline = partial inclusion Source: WHO Classification of digital interventions v1.0 115Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region than partners only when emergencies are ongoing. Emerging diseases know no borders and neither do digital technologies and data. While it may still be early to quantify the added value of mobile and digital technologies with respect to the COVID-19 pandemic response, there is emerging evidence that they do complement conventional public-health measures and contribute to reducing the human and economic impact of COVID-19. Analysis and use of data will depend on digital infrastructure and readiness of public-health systems. Countries and their health systems must be empowered to introduce digital health armamentariums to combat diseases and improve health. Areas of concern will have to be documented and managed. For instance, complicated and complex health information can cause concerns for patients and health care providers. The functionality of the systems in remote geographical areas, during a crisis and disaster, need to be well-thought-out. It is necessary to generate evidence of the effectiveness of digital health interventions and promote the appropriate integration and use of technologies. Going forward it will be important to address the legal, ethical and privacy concerns that the large-scale use of digital technologies brings. Several digital health interventions, particularly those that track individuals and enforce quarantine, can infringe on privacy while increasing risk among individuals with mental illness or restricted access to food or water. Government-implemented surveillance and control can instil fear and threaten civil liberties. People's privacy concerns for sharing information through potential digital platforms need to be considered. Another limitation of digital technology/digital divide is that it does not reach the ‘last person left behind’ which makes it even more important to improve last-mile connectivity so that no one is indeed left behind. Countries and their health systems must be empowered to introduce digital health armamentariums to combat diseases and improve health. Next steps z Countries should document and share experiences of the use of digital health technologies in combatting the COVID-19 pandemic. z Government leadership must be accelerated to evaluate and adopt digital technologies. Successful implementation of strategies will require carefully coordinated policies, with collaboration among governments, regulators, companies, NGOs and patient groups. z Making long-term changes to necessitate investment in national and international digital centres of excellence along with investment in workforce education and skills will help power a new digitally evolved public-health leadership that can guide future pandemic response. z Aligning international strategies for regulation, evaluation and use of digital technologies will strengthen pandemic management and future preparedness for COVID-19 and other infectious diseases. z Reducing the digital divide by developing tools and messaging that is accessible and can be tailored to specific risks, languages and cultural contexts is much needed. z Encouraging governments to find ways of providing greater transparency in their datasets, including epidemiological data and risk factors for acquisition with downloadable formats for researchers. z Peer reviewing more digital technologies and integrating them into public-health systems after rigorous testing and evaluation by digital health-evidence frameworks (such as evidence standards framework for digital health technologies of the National Institute for Health and Care Excellence). z Strengthening the penetration of technology so it can be uniform, especially in low-income neighbourhoods and remote areas where there is limited or no access to broadband signals, smartphones, or wearable technology like smart- watches is the need of the hour. Also, investing in training health care workers and end users to leverage technology for better health outcomes.

9 C H A P T E R Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 118 © W H O In di a/ G ho om ar M ah ila S am iti 119Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region THE VALUE OF RISK COMMUNICATION AND COMMUNITY ENGAGEMENT IN OVERALL PREPAREDNESS AND RESPONSE For public health emergencies, risk communication includes a range of communication capacities required through preparedness, response and recovery phases of public health events to encourage informed decision- making, positive behaviour change and maintenance of trust. Risk communication has evolved dramatically as social science evidence and new communication and media technologies and practices are constantly evolving. Communities are central to public health emergencies and engaging and empowering them is a cornerstone of emergency preparedness and response. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 120 E mergencies in the past decade in the WHO SEA Region have reaffirmed the importance of risk communication as a vital but complex intervention for public health emergencies. In emergencies, that are unexpected with an uncertain and evolving situation and with limited drugs, equipment and vaccines to mitigate damage, the actions and reactions of affected communities can make the difference between life and death. The goal of risk communication, therefore, is to ensure affected people get the right information on time and in a way that is easy to comprehend. Succeeding in that goal can be challenging because people are often frightened and in shock, trying to adapt to the on-ground situation. The vulnerability of affected people in an uncertain time may make them more susceptible to believing rumours and misinformation that could be potentially dangerous. Risk communication works to convince people to act responsibly to reduce the risk in an emergency, taking into account their needs, perceptions, traditions and cultures. It is a core capacity under IHR (2005) and all countries are obliged to strengthen their risk communication capacities. For decades, information has been conveyed to the public by the government, UN and reputed large organizations through traditional media, such as newspapers, television and radio. This was done via press conferences, press releases and briefings, along with engagement with community leaders at the grassroots level. Ensuring journalists understand and report health information accurately and convincingly for the community has therefore long been a priority for risk communication in public health emergencies. Over the past decade, however, as society transformed, the approach to risk communication in emergencies too changed. The fundamental source of this transformation has been technology. Increased connectivity and internet penetration, the proliferation of smartphones, and the emerging popularity of social media apps have fundamentally changed the way how information is shared and communicated. © W H O Key to ensuring people believe, understand and adapt to actions that will protect their health in emergencies, is trust in the source. Trust is a fundamental principle of risk communication. 121Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Internet proliferation and evolving risk communication in an ‘instant’ world Increasing internet penetration and the use of smartphones has meant that more people receive information from the internet. The internet and subsequent social media revolution transformed the nature of communication. Information is now no longer through media, government or big organizations alone. The explosive growth of social media has meant that everyone can now access and share information. This has led to the democratization of information sharing with every citizen being in a position to share information, ideas and opinions directly to and with others, instead of relying on traditional media and journalists alone. On the other hand, it has led to a plethora of information, some true, some false that is confounding and misleading people, making it hard for them to differentiate between credible and fake news. Rumours and misinformation, always present themselves in uncertain evolving situations like during public health emergencies where it spreads in seconds. This has a serious impact on the health and mental well-being of the community. The explosive growth of social media has meant that everyone can now access and share information. 2004, the year the great Indian Ocean Tsunami devastated six countries of the WHO SEA Region, was also the year when the social media app, Facebook was introduced. Although it was new, by 2006, it was clear it was transforming the way people communicated. To commemorate International Disaster Risk Reduction Day 2010, the WHO Regional Office for SEA successfully engaged one million people to build awareness and support for safe hospitals in disasters through a Facebook reaction test game. Click-a-brick: Safe hospitals campaign on Facebook in 2010 The devastating Nepal earthquake in 2015 generated unprecedented international and national media attention. Realizing that the media could be a powerful force for quickly disseminating information that was needed for the public, senior WHO officials spoke daily to the media, ensuring, at each step, that key messages for the public to protect themselves were highlighted and communicated. Field visits were arranged for media persons to ensure more impactful reporting. Making the media an ally during the Nepal Earthquake © W H O N ep al /P ra hl ad D ah al Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 122 The need to build capacity and systems for Risk Communication in Emergencies Reviews of the response to 2009 a (H1N1) pandemic revealed the need for strengthened risk communication systems in countries. The Thai Ministry of Health and WHO Report on the Joint Review of the Influenza Pandemic H1N1 2009, August 18 – December 6, 2009, found that although the country had a pandemic plan that included communication, in the social media era, the communication was responsive but slow. The report highlighted the lack of coordination between different departments and senior spokespersons, and conflicting messages led to lack of trust by the public. In addition to improved coordination, the report also emphasized the need for listening to the public, and for data from listening to be optimally organized, analyzed, and integrated to inform communication strategies and decision-making processes. Learning from the experience, Thailand revamped its risk communication approach and became the first country in the Region to have a risk communication unit within the Ministry of Public Health. Consequently, the risk communication around its MERS-CoV outbreak in Thailand was effective. In 2002 when Thailand reported SARS and recorded the death of two individuals and nine people being infected, a growing sense of fear gripped the country. A Task Force was set up, along with the Bureau of Public Relations. However, their approach was reactive and efforts were inadequate in calming the public. In 2009, during the A(H1N1) outbreak when social media was already present, confusing information was beamed from its different platforms causing some level of confusion with misinformation being spread by individuals. Announcements by government departments were not always coordinated and calls to helpline 1422 also revealed this lack of clarity in people’s minds leading to growing mistrust in the public authorities. A review of the emergency revealed “a key deficiency appears to be that no focal point was identified as responsible for ensuring communication was effective, consistent, coordinated and sustained”; and “many sources of information and data were not optimally organized, analyzed and integrated to inform communication strategies and decision-making processes.” Thailand reviewed and learnt from these experiences. After a 2012 review, the Bureau of Public Relations and the Bureau of Risk Communication and Health Behaviour Development focused on “communication intelligence” to guide decision making and instill public trust and confidence. This unit was integrated into the department of disease control, and any response decision included consideration of communication Thailand’s Risk Communication Response for MERS-CoV shaped by learnings from SARS intelligence findings and communicating the same to the community. MERS-CoV arrived in Asia in 2015 and on 20 May, the first case was reported in the Republic of Korea. Eventually, 186 cases including 26 deaths were reported. Asian countries were on high alert. In June that year, a 75-year old man from Oman was confirmed with MERS- CoV in Thailand. A Risk Communications plan was activated and there was a surge capacity as planned. External communication management included information provided by MoPH on MERS. Although social media was active, there was a parallel attempt to quash rumours and misinformation by translating facts and key messages by reaching out to embassies, media and others. Daily media briefings were held and a 24- hour hotline operationalized. In rural areas, trained village health volunteers went door-to-door to share information and two perception surveys further guided the information dissemination campaigns. Internal communication and coordination included daily updates with all government department heads and daily updates to all provincial health chiefs. National and Provincial Risk Communication was updated daily through Facebook and Viber groups and media and social media monitoring and analysis were undertaken. All this then fed back into response decisions providing clarity not just to the general population but also to all those involved in the response. Learning from the experience, Thailand revamped its risk communication approach and became the first country in the Region to have a risk communication unit within the Ministry of Public Health. 123Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region After the 2009 Influenza A(H1N1) pandemic and Ebola outbreak of 2014 in West Africa, it was recognized that an integrated, systematic approach to risk communication, based on listening to community needs, was essential. When the JEE system was developed for monitoring and evaluating core capacities, it identified five key areas of risk communication where the Member States needed to strengthen capacity. An analysis of JEE results for risk communication highlighted the strengths and gaps of Member States in the Region: ĥ Risk communication systems need to be in place in all countries, including an “all-hazards” risk communication plan, a risk communication function and a focal point in all MoH. Countries have limited technical and financial resources in this area, and these need to be strengthened. ĥ Cross-agency communication coordination is seen as a strength and more proactive engagement with all stakeholders, including local governments is needed. ĥ Public communication is strong in most countries, particularly media communication. Media spokespersons have been appointed but despite this, targeted and strategic communication based on an understanding of audience needs can be further consolidated. All countries need to strengthen social media communication and evaluate the impact of this communication. ĥ All countries have strong systems in place for community engagement, with networks of CHWs and volunteers having strong relationships with local community leaders, including religious leaders. Training them on risk communication for public health emergencies is needed. ĥ As internet and mobile penetration increases in the Region, rumours, fake news and misinformation can go viral and spread in minutes. SOPs for rumours and fake news monitoring, and public perceptions and concerns and proactive mitigation need to be in place, along with the allocation of budget and resources. Based on these findings, the WHO Regional Office for SEA developed a comprehensive risk communication strategy to strengthen risk communication in the Region. SEARO developed a comprehensive risk communication strategy to strengthen risk communication in the Region. Key components of risk communication Risk communication systems (plans, mechanisms) Public communication Addressing perceptions, risky behaviour and misinformation Internal and partner coordination Communication engagement with affected communities Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 124 SEARO Risk Communication Strategy To strengthen and establish risk communication for public health emergencies in a systematic way, SEARO developed the “Risk Communication Strategy for Public Health Emergencies in the WHO South-East Asia Region 2019–2023” which was endorsed by the Member States in the Regional Committee meeting in September 2019.(117) The regional strategy was based on WHO’s guideline for emergency risk communication policy and practice that was published in 2018. The Strategy, called “Five in Five” includes the following: 1. Risk communication structure for public health emergencies in all countries. Member States are encouraged to have a risk communication structure in place, comprising a risk communication unit (depending on the country size and resources), a plan that is regularly reviewed and updated and has adequate financing and human resources. WHO supports Member States in the development of a national risk communication plan and SoPs, and in building capacities. 2. Ensure mechanisms are in place at Regional, national and local levels so that all voices are consistent and coordinated in public health emergency preparedness and response. This can be achieved if Member States map all stakeholders and their roles in emergencies, have SoPs for stakeholders’ functions and a coordination plan. WHO can provide support through tools and templates for partner coordination and disseminating lessons from emergencies across the world. 3. Ensure strengthened Regional and national capacity for proactive, dynamic public communication, to address public perceptions and concerns. To strengthen public communication, Member States to have SOPs for media and social media, an identified media spokesperson and regular sensitization of media on key public health emergency issues. WHO to support the Member States in developing tools and templates for mapping, developing a repository of risk communication material and templates, and capacity building. 4. Develop systems and processes to ensure community perceptions and concerns are understood and integrated into public health emergency considerations. Member States have networks of CHWs and volunteers whose risk communication capacity needs can be strengthened and integrated into regular work. To ensure optimal engagement, community-based organizations and their roles can be mapped. Doctors trusted by communities can be trained in risk communication. Mapping and sensitization of community influencers will help in spreading outreach. WHO can provide support by documenting and disseminating lessons learnt from the Region and beyond, identifying and engaging Regional-level influencers, developing tools and capacities for community engagement and social science interventions. 5. Ensure adequate and sustained capacity to anticipate and combat fake news, rumours, and misinformation in public health emergencies. Combatting fake news and misinformation in real time is critical. Having an effective plan and system for rumour and fake news monitoring, analysis, and response, such as hotlines and regular media and social maps, tools and guides, and by disseminating global evidence and best practices on fighting fake news and misinformation. 125Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Building capacities for Risk Communication The WHO Regional Office for SEA has focused extensively, both at the Regional and country-level, on building capacity for risk communication. Capacity building for media was particularly important so that reporting is accurate in times of an emergency. Media workshops are held at the country level every year, to address issues ranging from outbreaks to natural disasters. Training health professionals in risk communication is also important. In 2018– 2019, workshops for health professionals were held in Sri Lanka, India, Nepal, Bhutan, Indonesia and Timor-Leste. Courses are also available on OpenWHO - WHO’s interactive, web-based platform that offers online courses for those preparing to work in epidemics, pandemics and health emergencies. (118) Developing Risk Communication strategies for COVID-19 The COVID-19 pandemic unfolded weeks after the SEARO Risk Communication Strategy was launched. The emphasis on capacity building and the need for a national plan and systems was highlighted during the pandemic, as risk communication was the only way to ensure that the virus did not spread, by ensuring people followed the prescribed public health and social measures. Managing the uncertainty and the infodemic was one of the biggest challenges given the new virus, its unknown characteristics and unpredictability. This led to the spread of fear, panic and a spread of instant information at an unprecedented level. Stigma, particularly against health care workers, was high. Although most countries engaged regularly with traditional media through interviews and press conferences, regular listening mechanisms and response to public concerns, remained limited. The COVID-19 pandemic has revealed the importance of a systematic but dynamic risk communication approach as an integrated part of preparedness and response, with data on public perceptions being used for decision-making along with epidemiological data. Implementation of the risk communication strategy, envisaging a well-staffed and well-resourced risk communication unit, and strengthened coordination, public communication and community engagement became essential. In one year from 2019 to 2020, internet connectivity in most countries in the Region increased by more than 5%. Going forward in the post-COVID-19 phase, the challenge of infodemics is only going to increase and in order to stay ahead of the curve, it would be important to invest in technology and systems to manage infodemics both through digital means and traditional community engagement. Engaging communities during Public Health Emergencies Communities are often first responders to any emergency. They swing into action even before the government or any local agency can reach them. What the community does before, during and after an emergency often shapes the outcome and impact amongst their population and setting. The way people interact and live, as well as their history, merits analysis to shape future interventions that place communities in the centre of both preparedness and response. Differences in political, cultural, religious and social structures among communities, their social norms and beliefs affect health behaviours and outcomes during outbreaks. It has been increasingly acknowledged in the past decade that a “whole-of-society” approach to disaster management is essential to successfully mitigate impact of disasters on lives and livelihoods of people. Community empowerment, therefore, is more than the involvement, participation or engagement of communities. It implies community ownership and action that explicitly aims at social and political change. Moreover, community engagement has consequences that go beyond information and prevention.(119) Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 126 Even as a digital revolution transforms communication, allowing anyone with internet access to instantly share news and updates as they happen globally, the COVID-19 pandemic was also plagued with an information deluge on digital platforms. This overload of information made it difficult to zero in on trustworthy and reliable sources. The phenomenon came to be referred to as ‘infodemic’ which is defined as a proliferation of both accurate and inaccurate information that spreads alongside an epidemic. It led to the evolving of a new field of ‘infodemiology’ which is the science of managing infodemics. The WHO Regional Office for SEA focused on infodemics within Risk Communication and Community Engagement (RCCE), a critical component of the Region’s “Strategic Plan to Strengthen Public Health Emergency Preparedness and Response 2019–2023” to advance implementation of IHR (2005). The COVID-19 pandemic triggered the establishment of a rumour and misinformation surveillance and response system (RMSRS) within the Regional Office. Subsequently, another separate system of digital monitoring and analysis of public perceptions and insights was set up to understand concerns around COVID-19, going beyond the mass generation and fuelling of rumours. In early 2020, the Regional Office partnered with private media monitoring organizations, initially DYellow Elephant and Media Measurement, to develop a system for surveillance of COVID-19 related rumours and misinformation in 11 major languages of 10 Member States. The system used AI software to scan content from open digital media platforms (Twitter, Facebook, YouTube, blogs and news websites), filtering content mentioning “COVID-19” or “coronavirus”. Content exceeding pre- defined levels of engagement (frequency of comments, reactions and shares of the post or content) for each country, depending on its social media volume, were prioritized for review. Rumours were logged into a repository, with manual analysis to prioritize response. An algorithm was used to determine appropriate responses based on the topic/theme of the rumour, the platform on which it was posted, source of the information, level of reach and engagement, including whether it was ‘trending’ (widely discussed or circulated online), and how harmful the rumour was to public health response. A level of risk was assigned, with low-risk rumours requiring only monitoring; medium-risk requiring monitoring and reinforcement of relevant facts in communications; and high-risk requiring rapid and aggressive risk communication response. Between 16 February 2020 and 15 February 2021, 58 million digital conversations relating to COVID-19 were scanned by the AI tool (approximately 170 000 per week after further filtering). Of these, 259 000 social media posts were submitted for human analysis to detect rumours (both misinformation and disinformation). Of these, 3307 rumours were identified and logged in the rumour repository. Between February and September 2020, the highest proportion of rumours (35%) concerned cures for COVID-19, making frequent reference to ayurvedic and herbal products. Rumours around transmission attracted the highest levels of engagement, often citing conspiracy theories around the origin of COVID-19. From November 2020 to January 2021, vaccines dominated the rumour mill. India, Indonesia and Nepal accounted for 75% of social media mention of selected misinformation categories. (Fig 1) 100 600 120 700 140 800 80 500 60 400 40 300 20 200 100 00 N o. o f Ru m ou rs M on it or ed N o. o f Co vi d- 19 c as es (i n th ou sa nd s) 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 2 4 7 Peak in 2021 due to vaccines rumours No. of Covid -19 Cases India Indonesia Maldives Bangladesh Other Infodemic Management and Rumour and Misinformation Surveillance and Response using Artificial Intelligence (AI) Tools FIGURE 1. Rumours and COVID-19 cases in SEAR by week (16 Feb 2020-15 Feb 2021 127Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region More community involvement Gets information or feedback from the community Develops connections CONSULT Better community involvement Involves more participation with community on issues Visibility of partnership established with increased cooperation INVOLVE Community involvement Forms partnerships with community on each aspect of the project – from development to solution Partnership building trust building COLLABORATE Strong relationship Strong partnership structure is formed Broader health outcomes affecting broader community. Strong bidirectional trust built SHARED LEADERSHIP Some community involvement Provides community with information Optimally established communication channels and channels for outreach http://www.dse.vic.gov.au/effective-engagement/introduction-to-engagement/what-is-community-engagement http://www.atsdr.cdc.gov/communityengagement/pdf/PCE_Report_508_FINAL.pdf INFORM Community engagement Modified from US Department of Health and Human Services and Victoria Government, Australia FIGURE 2. Five pillars of community engagement It is well known that ‘knowing is not doing” and while public communication creates awareness, to motivate people towards action to change their behaviour, engagement is also needed. Communities, therefore, are central to public health emergencies, and engaging and empowering them is accepted as a cornerstone of emergency preparedness and response. This has been recognized by the health sector after the Ebola Outbreak in West Africa in 2014 and re-emphasized during the COVID-19 response. The role of communities, and the importance of engaging them for emergencies, has been well documented. The Sendai Framework for DRR clearly delineates the need for broader community engagement in the development of national and local policy for disaster risk management. The IHR (2005) JEE Guidelines include community engagement as one of the parameters of capacity for risk communication. (120) Community engagement is critical to the success of many aspects of an emergency including following of protective measures. It is well known that ‘knowing is not doing” and while public communication creates awareness, to motivate people towards action to change their behaviour, engagement is also needed. In the large part, though not always, only when people are convinced, often due to conversations from a trusted source, whether a peer, parent, teacher, religious leader or another source they consider credible, do people get convinced and try to change their habits. Therefore, for uptake of protective and preventive behaviours in an emergency, community engagement is needed and it must go beyond just sharing of information. However, the extent to which communities can be engaged needs careful study. (Fig 2) Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 128 The 2015 Earthquake in Nepal: Using flash appeals to reach vulnerable communities Following the Nepal earthquake of 2015, the ability to build back and mitigate the worst impact of the disaster was attributed to the engagement of local communities affected by the disaster, as well as gender and social inclusion issues incorporated in the Nepal Risk Reduction Consortium. Reaching communities through various means, including local radio, and seeking their feedback shaped interventions that strengthened local resilience. Prior to the 2015 disaster, the UN Country team and the Government of Nepal laid a strong foundation for the response in the form of the Nepal Risk Reduction Consortium and the UN Development Assistance Framework. This foundation enabled drivers of humanitarian response to draw on existing analysis and data from development efforts, instead of starting from scratch with humanitarian assessments to inform the response. The country’s unique needs were outlined in the Framework, which had a strong focus on human rights, gender equality and social inclusion of vulnerable groups. Underpinned by extensive disaggregated analysis and assessments, the Flash Appeal was based on this vital data. The objective being to protect the rights of those most affected and promote inclusive access to humanitarian assistance, especially to most disadvantaged groups. From the onset of the crisis, the humanitarian community understood the importance of local engagement and accountability to the affected population, as well as gender and social inclusion issues. Feedback and outreach mechanisms were swiftly established to promote humanitarian efforts that were responsive to the needs identified by communities. This approach facilitated input from thousands of people on a regular basis, reaching 10 million people with communication products along with sex- and age- disaggregated data and reporting. More recently, the innovative Inter-Agency Common Feedback Project undertaken by the Resident and Humanitarian Coordinator’s Office prioritized and How countries in the region demonstrated ways of innovating and strengthening the community engagement strategies In 2010, Faridpur district of Bangladesh saw a Nipah virus outbreak. A previous outbreak in 2004, and response to the outbreak, left the local community suspicious and distrustful of authorities. Believing the outbreak to be caused by supernatural forces they drank raw date palm sap, which they assumed was the likely cause of transmission. When they fell sick and died in hospital, their perception took firm root that something was amiss with government authorities because despite their people getting admitted to hospital they failed to recover and died. A team of anthropologists and risk communicators went and spent time with the community. They first built rapport with them and observed and heard their views. They then reported that, “local health authorities, who announced initial prevention messages, did not provide any details nor responded to people’s queries.” The team conducted key informant interviews with faith leaders to understand community beliefs and perceptions about the illness, care-seeking and treatment practices. They communicated same prevention messages that earlier authorities had done, but in a more interactive way through house-to-house visits providing clarifications and response to queries. They explained the reason behind the prevention messages, giving the context of how the bacteria spread in cholera, a disease the community was familiar with. They showed the community infrared images of bats drinking date palm sap at night and explaining how the virus worked. They used pictorials and cards to explain care-seeking and treatment, providing solutions that were culturally relevant. “During our conversations, we did not tell them to stop drinking raw date palm sap, rather we acknowledged and appreciated its cultural importance and suggested boiling instead so they could enjoy date palm sap, but also minimize risk.” Further, the team added, “We also did not tell them to stop other cultural practices like ritual bathing of a corpse but instead asked them to cover their mouth and wash their hands and body with soap afterwards to minimize the risk of transmission.” The team concluded, “an interactive strategy communicated by trained experts, using lay language with supporting evidence can make the biomedical model of disease transmission and prevention messages credible.”(121) Nipah Virus outbreak in Bangladesh: “It’s not what you say, it’s also how you say it” © W H O / Pa yd en 129Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region promoted community engagement seeking feedback through periodical perception surveys, rumours and concerns tracking along with existing feedback mechanisms. The information was formulated into consolidated reports that were shared with humanitarian actors, as well as civil society and district authorities, resulting in adaptive programming and planning to ensure that response efforts were aligned with community-raised concerns and needs. Using local radio and community meetings, enquiring people could gain relevant and accurate information—something highly valued by affected communities. (122) The Ministry of Public Health manages 1.04 million village health volunteers across Thailand, including 15 000 volunteers in Bangkok. Decades-long investment of village health volunteers in the country helped reduce SARS-CoV-2 transmission and improve psychosocial support, health promotion, contact tracing and assuring adherence to quarantine and isolation. Nationwide, from 02 to 26 March 2020, village health volunteers visited 3.3 million households. Between 27 March and 11 April, they visited eight million additional households to look for potential cases of COVID-19 and helped with prevention and control efforts. This helped reduce Community participation is playing a crucial role in shaping the COVID-19 pandemic response. Vaccine roll-out involves vaccination of adults, especially the elderly. The current vaccination campaign is different from previous ones where target groups were children, with exceptions like influenza vaccination. Adult perception of vaccines is different from those involving children. COVID-19 vaccines have been developed and regulatory approval fast-tracked for emergency use while maintaining safety and using innovative technology. These and other factors led to rumours and misinformation, further amplified by social media. Another issue relates to complacency that sets in once the vaccine is taken and perceived as a ‘magic bullet” cure. Community engagement in such situations assumes critical importance, persuading them to vaccinate and continue taking precautions for their and others’ safety. The CHWs play an important role in creating awareness amongst community members on COVID-19 vaccines. In India, thousands of health workers were trained in the run-up to the vaccine rollout. In Thailand, village health volunteers created awareness on vaccines and other protective measures. In Bhutan, developing trust between CHWs and communities is key in their successful vaccine roll-out. In Nepal, female community health volunteers are working to ensure vulnerable groups receive the vaccine in hard-to-reach areas. Faith leaders are playing an important role in Indonesia with religious organizations like Muhammadiyah and Nahdlatul Ulama working with government and RCCE partners (UNICEF) using interpersonal communication techniques to increase vaccine uptake. Majelis Ulama Indonesia (MUI- Indonesian Ulema Council) provides halal certification and works with WHO and IFRC to overcome challenges related to vaccine hesitancy. Since late 2020, Wahana pressure on hospitals and clinics and allowed EHS to continue without disruption. They reassured people during an uncertain and anxious time by strengthening a sense of safety and self-care, easing the social stigma that people had to face when they and their actions/ behaviours were being investigated and questioned. Village health volunteers kept themselves updated about the pandemic and latest operational guidelines through an app designed especially for their use. Primary health-care personnel also made judicious use of social media group chats. (123) Visi is reminding people of the importance of routine immunization and urging communities to get vaccinated. In India, faith leaders were sensitized and engaged by RCCE Working Group partners to share important details with their congregation. In Sri Lanka, a meeting was held with religious leaders with the island-wide representation of Buddhists, Hindus, Muslims, Catholics/Christians and Bahais. The MoH along with the WHO country office, Alliance Development Trust (local CSO) and relevant stakeholders discussed the role of religious leaders in the vaccine roll-out and community engagement process. In the Maldives, faith leaders were sensitized to encourage their congregation to take protective measures and vaccines. In Timor-Leste, faith leaders were sensitized to the importance of vaccination and asked to share video messages with followers. Apart from faith leaders, many community-based groups have taken initiatives to get their villages and adjoining areas fully vaccinated. In India, 4000 rural women from a self-help group in Rajasthan (Ghoomur Mahila Samittee) went house-to-house encouraging vaccination and adoption of protective measures. They established water tanks at public places to facilitate handwashing. Water Aid NGO reached out to communities in markets during festivals and slums, creating awareness on COVID-19. Delhi-based DISHA Foundation is working with migrants providing information on vaccines and facilitating them in registering on the government app. In Sri Lanka, tri- lingual FAQs were developed by the WHO country office with inputs from the Regional Office and MoH. These were distributed via WhatsApp and posted on the website. A tri-lingual advocacy booklet for parliamentarians, religious and community leaders was also developed with the support of the Rotary Club in addition to training on vaccine awareness held by Sarvodaya, a local CSO. COVID-19 response in Thailand: Addressing needs of people under the lockdowns Overcoming COVID-19 vaccine hesitancy in Indonesia, India, Nepal, Sri Lanka, Bhutan, Maldives and Timor-Leste Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 130 Understanding the complex nature of community engagement Community engagement in public health emergencies is complex because communities are complex. It involves multiple individuals and groups of individuals, who vary in terms of education, social standing and social inclusiveness. The success of community engagement depends on taking these factors into account as well as the dynamics within the community. Therefore, the top-down approach of merely informing a community rarely achieves the goal. Enablers of community engagement in public health emergencies depend on a number of factors (124): The JEE of IHR (2005) includes community engagement as a measure of risk communication capacity in countries. The indicators include health promotion/ community engagement unit working for emergencies, the inclusion of community engagement in national plans, a functional feedback mechanism with communities at risk and baseline social data, intelligence and analysis on factors that may increase the population’s risk to the top five public health hazards in the country – such as living conditions, language, influencers and trusted channels of information. Of the countries in the Region that had a JEE, four countries got a rating of four, out of a maximum of five. Another four countries scored three and only one country scored two. Among common best practices identified in SEAR countries, during the JEE evaluations for community engagement it was found that: ĥ all countries have public health volunteers that engage and communicate with the community. Their role is critical, and they are often the most trusted by the community; ĥ hotline numbers and SMS services are in place in many countries for communities to seek information from; ĥ feedback mechanisms are seen as a reliable way of monitoring public perceptions and concerns; and ĥ grassroots NGOs and civil society organizations working in health serve as a bridge between the community and government authorities. Existing relationships and trust between the community and local institution/government; Deep understanding, well before the emergency occurs, of communities, their dynamics, leadership, and perceptions of the emergency; Understanding and building on existing practices of cultural beliefs, expectations and respect for local contexts and priorities; Estimating capacities, needs and resources of the community and reviewing existing support networks, ways in which they procure information with a specific focus on the most vulnerable, sense of community ownership and their corresponding levels of active interest. The JEE of IHR (2005) includes community engagement as a measure of risk communication capacity in countries. 131Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Risk communication and community engagement to serve as a valuable tools to guide the course of future emergency response Countries in the SEA Region have invested in community engagement, but, as the COVID-19 pandemic revealed, greater investments are needed to reach larger groups of the population. Strengthening health volunteer programmes are low- cost investments with immense potential. With respect to COVID-19, community engagement can be critical to creating local and context-specific solutions to prevention and control measures. Through a ‘bottom-up approach’, communities must participate in decision-making processes of planning, designing and delivering services aimed at improving the local population’s health and reducing health inequalities. Going forward, a lot will depend not just on engaging with communities but processes adopted on the engagement. Grassroots NGOs and civil society organizations working in health will serve as a bridge between communities and government authorities. More social data on local cultural contexts will make communities more accountable and help them adopt healthy behaviours. Understanding the power dynamics and influences within their cadres will shape the nature of engagement and rapport building. Larger investments will have to be made in training and sensitizing public health staff and CHWs on culturally sensitive ways to communicate with local populations and win their trust. These efforts will strengthen resilience and empower people as they adopt behaviours that can help them survive future emergencies and disasters. Grassroots NGOs and civil society organizations working in health will serve as a bridge between communities and government authorities. © W H O In di a/ W at er A id

10 C H A P T E R Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 134 © W H O /B an gl ad es h 135Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region ADDRESSING CONCERNS OF VULNERABLE POPULATIONS: THE ROHINGYA CRISIS In the complex refugee camp setting in Cox’s Bazar, quick and timely coordination and setting-up of health infrastructure provided essential components of the public health strategy. The involvement of communities in decision-making helped build trust and improve health-seeking behaviour. Under the leadership of the Government of Bangladesh, coordinated efforts of the donor community and humanitarian partners limited the impact of COVID-19 on refugee and host communities. As WHO led the health sector response, it adapted to ground realities, disease outbreaks and day-to-day challenges through a multipartner approach that addressed concerns of all age groups and situations. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 136 O n 25 August 2017, a large exodus of Rohingyas from Myanmar to Bangladesh occurred after a short period of violence where the Myanmar army was involved. The Rohingyas are one of the many ethnic minorities in Myanmar representing the largest group of Muslims in the country, with the majority living in the Rakhine state. They have their own language and culture and have been in the region for generations. The initial influx of Rohingyas to Bangladesh occurred in 1978 and continued up to the 1990s. There were an estimated 220 000 unregistered refugees in the Cox`s Bazar area prior to the 2017 influx. According to the International Organization for Migration (IOM), over the course of August to November 2017, about 700 000 people sought shelter in Bangladesh where they still live in hastily built settlements and camps. The Government of Bangladesh (GoB) allocated land and housed them in and around the two major areas of Kutupalong and Nayapara settlements, and in other areas in Teknaf and Ukhia. The Kutupalong settlement has nearly 620 000 people with earmarked land comprising of remote, hilly terrain which at the time had no established infrastructure or roads linking it to Cox’s Bazar and other towns. Altogether the refugee population is now close to a million people, making this one of the largest refugee crises in the world. The GoB classified the Rohingya people as Forcibly Displaced Myanmar Nationals (FDMNs) seeking refuge in Bangladesh and not as refugees. © W H O /S EA RO 137Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Initial emergency response The response to the refugee influx was swift and large-scale. The GoB deployed army and disaster teams to help in the first few weeks backed by a strong national civil society response. A massive international response was launched in support of the national and local efforts, with the UN and international NGOs. WHO was on the ground in early September 2017, supporting measles and cholera vaccinations and setting up disease surveillance. The Incident Management System (IMS) was initiated, triggered by a Grade 3 Emergency grading. The WHO Country Office had the overall leadership with an Incident Manager in Cox’s Bazar. Subsequently, a sub-office was established with its Head being replaced by the Incident Manager in line with the reclassification of the crisis as a protracted emergency. Many lives were saved because the initial effective response added to the joint efforts of the GoB, civil society organizations, international actors including the UN, The International Red Cross and Red Crescent Movement and international NGOs. A mortality survey conducted by the international humanitarian organization, Médecins Sans Frontières (MSF) early in the response showed the crude mortality rate (CMR) below emergency thresholds for most of the first year. In previous mass movements of Rohingyas in 1978, it is estimated that 10 000 people died in poor living conditions in the camps. There have been significant improvements in management and effectiveness of the response to disasters and the humanitarian crisis over the last 10-15 years. A major reform of humanitarian coordination was introduced in 2005 to enhance predictability, accountability and partnerships. This included the cluster approach where groups of humanitarian organizations, both UN and non-UN, are given responsibility for the main sectors of humanitarian action, e.g. food security, shelter, health, water, sanitation and hygiene and logistics. They are designated by the Inter-Agency Standing Committee (IASC) and have clear responsibilities for coordination. WHO was assigned the role of Cluster Lead Agency (CLA) for health. The Resident Coordinator and/or Humanitarian Coordinator (RC/HC) and Humanitarian Country Team (HCT) manage humanitarian response through the clusters. (125) Access to health care service delivery During the initial period, refugees that needed health care were sent to government hospitals and clinics run by NGOs. The existing government health care facilities were overburdened. The Sadar District Hospital in Cox’s Bazar and Teknaf and Ukhia upazilla health complexes and primary health care (PHC) units were not equipped to handle the huge influx of Rohingya refugees. The health facilities were running full capacity to meet the needs of both, the new arrivals and host populations living in the area. Severe acute malnutrition (SAM) was observed in 7.5% of the children under five which was well over the emergency threshold. Local health care facilities and NGOs had limited capacity to treat them. However, within a short time, there were at least 65 health partners providing direct health services to the refugees. While government hospitals played an important role in health service delivery, in particular for emergency and in-patient care, several field hospitals were established in the camps. Catering to nearly one million refugee population, the need for hospital care was substantial. This further aggravated during the period with the diphtheria outbreak in 2018 and COVID-19 outbreak in 2020–2021. (see box below) The cluster approach ensures that international response to humanitarian emergencies is predictable and accountable with well- defined leadership that allows division of labour between organizations and demarcation of roles and responsibilities in different areas. WHO`s Emergency Response Framework reflects that the Organization has specific responsibilities and accountabilities for emergency operations under IHR (2005) and within the global humanitarian system as the Global Health Cluster Lead Agency. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 138 Health facilities run by many partners were not equally distributed throughout the camps and demonstrated variable technical capacity and quality of services. Almost all regular health programmes were available in the camps with most making referrals to government health facilities. BRAC, a large Bangladesh NGO, took on the task to implement the TB programme for the refugees under the supervision of the National Tuberculosis Control Programme. The immunization coverage among the Rohingya population was low, resulting in outbreaks of VPDs such as measles and diphtheria. The immunization programme was closely implemented with the support of district and upazilla health authorities and local staff. WHO played an important role in coordinating the immunization programme and engaged field monitors to identify families with unimmunized children. WHO provided technical support in many different areas. A survey conducted by the Country Office with technical support from WHO HQ and the Regional Office for SEA in 2018 looked at availability and quality of essential medicines in the camps. They used the WHO Essential Medicines and Health Products Price and Availability Monitoring Mobile Application (WHO EMP MedMon) based on elements of the well-respected WHO/HAI methodology for “Measuring medicine prices, availability, affordability and price components”. Among the health facilities visited as part of the survey, 64% faced stockout within six months. These stockouts were due to increased inflow of patients due to outbreaks or communication gaps between service providers and supply chain personnel. Also, 78% of tracer medicines found in facilities were produced in Bangladesh while the rest were imported or donated, mainly through international organizations. The study’s recommendations included: Quality assurance of essential medicines is an integrated system of activities involving planning, quality control, quality assessment, reporting, and quality improvement to ensure that a product or service meets defined standards of quality with a stated level of confidence. Rapid monitoring, risk-based post marketing surveillance, sampling, testing and reporting are vital elements to control substandard and falsified medicines from infiltrating the medicines supply chain. Post-marketing surveillance is a key regulatory function and refers to the set of comprehensive quality surveillance activities. Cox’s Bazar is situated in a geographical border area, where there is a high risk of influx of unregulated medicines. Lack of appropriate regulatory mechanisms to control their distribution and storage leads to high chance of deterioration in the quality of medicines during and/or after delivery. The regulatory oversight in the refugee camps is limited due to limitations in human and financial resources and challenges in licensing and monitoring of medicine outlets, especially during the early stages of the emergency. With technical support from WHO and partners, a system for post-marketing surveillance of medicines Establishment of a field-based system for post-marketing surveillance of medicines was developed based on the draft National Guidelines on Risk-Based Post-Marketing Surveillance. The system involves collection of samples from the field according to defined criteria, screening samples through preliminary tests conducted using MiniLabs and escalating failed samples to the National Control Laboratory in Dhaka. To support this effort, WHO conducted a rapid assessment of the essential medicines situation in Cox’s Bazar which identified the main risks related to quality of medicines. Three MiniLabs were procured by WHO for screening samples and training was delivered to staff from the Directorate General of Drug Administration (DGDA) and development partners on risk-based post-marketing surveillance including conducting the physical and chemical tests using MinLab. The system is facing logistical and technical challenges due to limited financial and human resources, high staff turnover, difficulties in collecting samples and limited space at DGDA field-office for conducting tests. WHO is working with DGDA, United States Pharmacopeial Convention and partners to operationalize the system and enable the DGDA local office to perform the sample collection and testing in a timely and efficient manner. WHO and partners developed a health dictionary in the Rohingya language to aid communication by health workers. 139Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region ĥ developing a post-market surveillance system for monitoring the quality of medicines in the camps; ĥ standardizing good storage and distribution practices; and ĥ considering practice changes around NCD management in lower-level health services to facilitate patient adherence. Risk communication and working with community leaders to reach out with health messages was essential. WHO worked with “Translators without Borders” to develop a health dictionary in the Rohingya language so health workers could better understand health problems. WHO also worked with “Save the Children” to engage young people as health messengers taking lifesaving information to families. In 2020, services inside the camps were reduced and some organizations had to stop, making the provision of health service delivery more challenging. Challenges faced by the host community As of 2021, an estimated 3 million people live in Cox`s Bazar district, excluding refugees. The district had camps and settlements of Rohingyas prior to the influx of refugees in 2017 which were supported by international organizations. The large-scale arrival of over 700 000 new refugees had a significant impact on the local community. The huge humanitarian response provided economic activity and job opportunities in Cox`s Bazar and surrounding districts, but also put pressure on food prices and health services. It was therefore imperative for the host community to be included in the overall humanitarian response. WHO with donor support launched a project in 2018 to increase the capacity of the Sadar District hospital, including renovations of wards and operation theatre complex, providing medicines, medical supplies and equipment, training and operational assistance. Through ‘Additional Financing for the Health Sector Support Project 2019–22’ from the GoB and World Bank, WHO and health partners are working to address existing gaps in health services in Cox’s Bazar to further support the government- led health response in the district. The purpose being to accelerate the work on capacity building and ensuring provision of essential services in 45 designated health care facilities through a strategic multisectoral approach and increase direct investment in local public health institutions. Other multilateral organizations, including the Asian Development Bank (ADB), are involved in strengthening infrastructure as a way to stimulate the development of the local economy. Disease surveillance and control of disease outbreaks In humanitarian emergencies, where the risk of transmission of infectious diseases increases, an effective disease surveillance system is essential to rapidly detect and respond to disease alerts and outbreaks. WHO and the Ministry of Health and Family Welfare (MoHFW) established an Early Warning, Alert and Response System (EWARS). WHO trained health care workers on disease surveillance, standard case definitions and how to complete the EWARS reporting form. A gradual increase to more than 100 sentinel surveillance sites in camps reported daily on diseases with outbreak potential such as diarrheal diseases, acute respiratory infections and vaccine-preventable diseases. This facilitated rapid case investigations and active case finding. Since 2017, there have been several disease outbreaks in the camps and the WHO epidemiological surveillance team comprising of international and national experts has played an important role in containing these outbreaks. This has depended on collaboration with the Civil Surgeon in Cox`s Bazar district, MoHFW, health sector partners and national institutions such as icddr,b. The ability to work across sectoral teams has been essential; working with WASH has for example been crucial for controlling waterborne disease outbreaks. Since 2017, there have been several disease outbreaks in the camps and the WHO epidemiological surveillance team comprising of international and national experts has played an important role in containing these outbreaks. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 140 Health sector coordination and difficulties in managing ground realities The health sector coordination was led by WHO from 01 October 2017 in collaboration with GoB. A Strategic Advisory Group (SAG) was established comprising of MoHFW, WHO and select health partners such as BRAC, IFRC, MSF, IOM, UNFPA and UNHCR. The WHO represented the health sector during the Inter-Sector Coordination Group (ISCG) meetings in Cox’s Bazar and acted as the secretariat for the Emergency Coordination Committee set up by the government to lead the initial health response. Information management was initially handled jointly by IOM, UNFPA and WHO and later taken over by WHO as part of being Cluster Lead Agency (CLA). Information management has been a critical part of the health sector. The annual Joint Response Plan for Rohingya Humanitarian Crisis (JRP) was prepared by different sectors. Guided by the Health Sector Strategic Plan developed in 2018 and the yearly Joint Response Plans, WHO mounted its health sector response in Cox’s Bazar with approximately 80 partner organizations providing primary, secondary and specialized health services in health facilities in and around the 34 highly congested refugee camps. Six Health Sector technical working groups facilitated collaboration in distinct technical areas of emergency preparedness and response, sexual and reproductive health, mental health and psychosocial support, community health, clinical case management and epidemiology. WHO also developed a Health Cluster Guide to define and describe the role of sector coordination. (126) Soon after the influx in 2017, the Health Sector, led by WHO, developed the Minimum Package of Essential Health Services, defining two levels of primary health care: ĥ Health posts (similar to community clinics in the Government system, and basic health units according to Sphere standards, currently numbering around 100); and ĥ Primary health centres (similar to union-level sub-centres and counted as health centres according to Sphere Standards, currently numbering around 40). © W H O /S EA RO WHO also developed a Health Cluster Guide to define and describe the role of sector coordination. 141Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region WHO as health sector coordinator, commissioned an External Review of Health Service Delivery in 2018 to inform health sector partners of current gaps, challenges and best practices. Its findings were used to improve coordination, rationalization and effective targeting of the health sector’s response. Catchment populations were agreed, and a rationalization exercise in 2018–2019 ensured a geographically rational distribution of health facilities across camps. A network of camp health focal points was established to monitor adherence to minimum standards for primary health facilities. Initially reliant on internationally deployed field hospitals and EMTs, referrals to secondary and tertiary Government facilities at sub-district, district and divisional levels have since been established. The SOPs were applicable to all partners who provided guidance. As in other remote areas of Bangladesh, recruitment and retention of qualified health care workers for Rohingya camps is challenging for both Government and NGO partners. Partners report that the approximately 5000 health workers working in health facilities serving the camps are often newly graduated, have limited clinical experience and demonstrate a high turnover. In line with the Sphere standards for such situations, WHO invested in continuous capacity building for health partners’ staff across technical areas to meet professional standards, including communicable diseases, child health, sexual and reproductive health, injury and trauma care, mental health and psychosocial support and non-communicable disease. Despite considerable efforts, quality of care remains uneven across partner organizations and facilities and remains an area that needs to be continually monitored and supported. To have evidence to lead public health interventions, the EWARS and within the national DHIS-2 system, a specific module for the Rohingya crisis was developed in 2018 to capture health services data and rolled out across the camps. Through activity reporting in a specially designed 4Ws system, performance and gaps were identified swiftly across partner organizations and camps. Aggregated data and analysis of data across platforms was shared via information products, with health intelligence for the wider humanitarian community, including online dashboards, weekly Situation Reports, in-depth Quarterly Bulletins and ad-hoc products such as infographics, maps and special reports. Efforts to further standardize and simplify reporting requirements, enhanced the quality of data and analysis to guide public health response with evidence and research which are ongoing.(127) WHO-led health partners in the camps in the preparedness and response for emergencies, including cyclones and heavy monsoon rains, as well as outbreaks of communicable diseases. When cholera cases were identified in the camps in late 2019, a Multisectoral Acute Watery Diarrhea Preparedness and Response Plan that was developed by WHO for Health and WASH actors allowed for a swift detection and effective response to initial cases. Mass vaccination campaigns took place from 2017–2020 and continuous disease surveillance through health facilities and communities remains a priority of the response. CHWs visit each of the 211 000 households on a weekly basis for health promotion and community-based surveillance. Meanwhile, the focus of the response also shifted to monitor and address chronic conditions, with NCDs emerging as an important concern. An Operational Review of WHO’s response to the Rohingya crisis in October 2018 identified WHO’s mandate to operate both in humanitarian and development settings as a strength to ensure an uninterrupted transition towards medium term-oriented approaches. Now, in a protracted emergency phase, nearly four years after the initial influx, the response is becoming increasingly localized with Government authorities taking up a stronger leadership role, and national staff and organizations playing key roles within the humanitarian response. WHO-led health partners in the camps in the preparedness and response for emergencies, including cyclones and heavy monsoon rains, as well as outbreaks of communicable diseases. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 142 Living conditions and future prospects There are currently around 860 000 Rohingya refugees in Cox’s Bazar living in more than 30 camps. The initial temporary shelters have been made permanent with congested living conditions. Water supply and toilets are available but they are far from satisfactory, including lack of gender-separated toilets and bathing areas. A road network has been made, but with frequent landslides occurring during the monsoon season. There has been a focus on the monsoon and cyclone preparedness led by UNHCR and IOM, including geospatial hazard mapping and cyclone forecasts. A lot of efforts have been made to improve living conditions in the camps. However, overcrowding and shortage of land is a major cause of unsatisfactory standards, coupled with the uncertainty of prospects for the Rohingya refuges. The UN and UNHCR have been promoting access to durable solutions for refugees from the beginning of the Rohingya crisis, encouraging and helping create conditions conducive for their return to Myanmar. The Governments of Myanmar and Bangladesh signed an MoU in November 2017 on the return of Rohingya refugees to their homes in Myanmar's Rakhine state. However, only a small number could do so under the scheme of Voluntary Repatriation to Myanmar. Meanwhile, the GoB has plans for relocating some of the refugees to the island of Bhasan Char in the Bay of Bengal. About 20 000 refugees have been relocated there since December 2020, while the government eventually plans to relocate around 100 000 people and provide them health services with the help of select national NGOs. Tensions have been on the rise in the camps, especially during the COVID-19 outbreak. A lot of the physical movement is restricted with the help of security personnel. There are intermittent issues like the March 2021 fire that swept through the settlements damaging about 10 000 shelters and displacing 45 000 refugees. The UN and UNHCR have been promoting access to durable solutions for refugees from the beginning of the Rohingya crisis, encouraging and helping create conditions conducive for their return to Myanmar. © W H O /S EA RO 143Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region An increase in the number of suspected measles cases among the newly arrived Rohingyas and the host communities prompted the Government and UN partners to step up immunization efforts. Nearly 360, 000 people in the age group of six months to 15 years among the new Rohingya arrivals and the host communities, irrespective of their immunization status, were administered measles and rubella vaccine through fixed health facilities, outreach vaccination teams, and at entry points into Bangladesh. A mass oral cholera vaccination campaign was conducted in October and November 2017. In November 2017, an outbreak of diphtheria was first identified in Kutupalong campsite and spread quickly to become a major public health threat with 440 cases reported during the first month. A rise in cases during early December led to a collaboration between teams from MSF—who were running a provisional diphtheria treatment centre— and the London School of Hygiene and Tropical Medicine (LSHTM) with the goal to use transmission dynamic models to forecast the potential scale of the outbreak and the resulting resource needs. The congested conditions in the camps with poorly ventilated shelters, poor health-seeking behaviour, low immunization coverage of the refugees, in particular children and young adults, lack of clean water and proper sanitation facilities were conducive to the rapid spread of the epidemic. A specialist team from WHO was assigned to work with the MoHFW to spearhead the response to the increase in diphtheria cases. The District Diphtheria Core Committee chaired by the Civil Surgeon of Cox’s Bazar was formalized with WHO facilitation. Sub-groups on epidemiology, case management, risk communication, laboratory, vaccination, and logistics were formed under the aegis of the core committee comprising of key partner agencies that supported the response. They met regularly to prioritize actions and implement harmonized interventions. The Diphtheria Health Sector Response plan was finalized in coordination with the Director General of Health Services and health sector partners. WHO and GOARN team established a network of partner agencies that acted as focal points for surveillance, treatment, contact tracing and referrals for diphtheria and other outbreak prone diseases. This facilitated daily sharing of information between agencies with the deployment of a team of trained epidemiologists, vaccine specialists and technical experts. WHO in partnership with the MoHFW implemented the EWARS across the Rohingya health facilities. The web-based system and mobile application enhanced disease surveillance and outbreak detection with its analytical and alert modules that signalled the outbreak in the early stages. They also incorporated a risk assessment framework and matrix that provided useful inputs in the response. Getting a laboratory confirmation of the diphtheria cases was difficult. The Institute of Epidemiology, Disease Control and Research (IEDCR) Field laboratory in the Cox’s Bazar Medical College was therefore strengthened with WHO support. As part of the division of labour among health sector partners, MSF provided initial care and treatment for Managing a Diphtheria outbreak in a refugee camp diphtheria patients and later expanded it to include other partner agencies. One of the challenges was to ensure rapid access to Diphtheria Antitoxin (DAT) because of a limited number of suppliers globally. However, the WHO Regional Office for SEA procured and shipped DAT to Bangladesh as part of its emergency efforts. IOM also opened a new treatment and isolation centre in Kutupalong with additional treatment and isolation centres in Kutupalong extension and Leda camps. Several EMTs from the UK arrived in mid- 2018 to support treatment of severe diphtheria cases within the newly operational treatment and isolation centres. Training of health workers was prioritized to ensure they knew how to distinguish diphtheria from an ordinary sore throat since health workers had limited practical experience of handling diphtheria since it was not an endemic disease in Bangladesh. A home visit programme was rolled out to check on families and close contacts of those with diphtheria to provide them with a seven-day course of oral antibiotics as a preventative measure and contain transmission of disease. Health staff immediately referred any suspected cases to any of the nine Diphtheria Treatment Centres operated by Bangladesh Red Crescent, IOM, MSF, or Samaritan’s Purse. The staff from other parts of the response like shelter and child protection were trained to detect signs of the disease. This included partner’s networks of teachers at Temporary Learning Spaces and Child-Friendly Spaces. Cultural and language barriers with little knowledge about diphtheria empathized the importance of working with refugee communities and offering risk communication. A mass three-dose vaccination campaign was organized providing tetanus-diphtheria vaccines for children aged 7 years to 15 years, as well as pentavalent vaccines (diphtheria, pertussis, tetanus, Hemophilus influenzae type b, and hepatitis B) and pneumococcal conjugate vaccines (PCV) for children aged 6 weeks to 6 years. Aid workers and volunteers working in different programmes were also vaccinated. The vaccine was provided by the MoHFW with support from WHO and UNICEF. A total of 9275 cases of diphtheria were reported. Because of limited experience in managing large-scale outbreaks of diphtheria globally, WHO organized a workshop in Cox’s Bazar with the participation of Civil Surgeon, Cox’s Bazar, Refugee, Relief and Repatriation Commissioner (RRRC), MoHFW Coordination Cell, MSF, Samaritan’s Purse, UNICEF, ECHO and with online participation from WHE and IVD Regional Office of SEA, US CDC in Atlanta, and GOARN in Geneva. The main objective was to bring the outbreak under control with discussion among local and national health authorities, health partners working in Cox’s Bazar and with technical advice from international experts. Recommendations were made post the workshop on an immunization schedule for refugees and host community, use of case definition, laboratory strengthening and contact tracing and chemoprophylaxis. Dr. Balwinder Singh Chawl, Medical Officer IVD (Bangladesh WCO & Previous Health Sector Coordinator, Cox’s Bazar) and Dr. Muhammad Khan, National Professional Officer, Disease Surveillance and Epidemiology Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 144 WHO-led response to COVID-19 in Rohingya Refugee camps in Cox’s Bazar Almost four years since the displacement of more than 742 000 Rohingya people from Myanmar into Bangladesh, the situation in Cox’s Bazar has evolved from an acute crisis into a protracted humanitarian emergency. Due to the high population density and difficult living conditions in the camp setting, concerns were high on the impact that COVID-19 would have in the world’s largest refugee camp. On 08 March 2020, the Bangladesh MoHFW reported the first COVID-19 case in the country. On 15 April 2020, Cox’s Bazar reported the first case of COVID-19 among the host population and on 15 May 2020, the first case of COVID-19 in the Rohingya camps of Cox’s Bazar. COVID-19 preparedness and response plan. In March 2020, before the first case of COVID-19 was detected in Cox’s Bazar, WHO and partners developed preparedness and response plans to reduce excess morbidity and mortality among refugees as well as host populations. A pillar-based response structure was designed, following the framework guidance on COVID-19 Strategic Preparedness and Response Plan from WHO. The Cox’s Bazar multisectoral plan was anchored in eight pillars that covered coordination, case management, laboratory, IPC, surveillance, case investigation and contact tracing, points of entry, Risk Communication and Community Engagement (RCCE), and operations and logistics. An addendum to the Joint response plan was developed to support resource mobilization and guide mechanisms of COVID-19 response in Cox’s Bazar. Coordination. Overall coordination of the international response to COVID-19 in the Rohingya camps was led by WHO in support of the office of the Civil Surgeon of Cox’s Bazar, the RRRC and MoHFW Coordination Cell. To support effective operationalization of the response, pillar-wise coordination platforms were set up with the RCCE Technical Working Group (TWG), the IPC TWG and the Surge Case Management TWG. In collaboration with the Protection and Gender sector, the health sector coordinated mainstreaming efforts on Prevention of Sexual Exploitation and Abuse (PSEA), Gender-based Violence (GBV) and child protection into its COVID-19 response plan. Surveillance. Guided by WHO surveillance guidance on COVID-19, a surveillance strategy and SoP was prepared, and existing syndromic surveillance of ARI data and sentinel testing of ARI cases incorporated to strengthen surveillance and testing among Rohingya refugees. Additionally, under enhanced Community Based Surveillance, CHWs identified individuals with symptoms associated with COVID-19 and by 2020, more than 58 628 suspected cases were referred by CHWs to SARI ITCs. WHO standard case definitions for COVID-19 were adapted to the camp setting in Cox’s Bazar since early April 2020. Rapid Investigation and Response Teams (RIRTs) were set up and Camp Health and Disease Surveillance Officers (CHDSO) were recruited to conduct investigation and contact tracing within 24 hours of any alert. The RIRT and CHDSOs implemented the public health response to cases at the camp level, including the institution of isolation and quarantine that have been effective in controlling the spread of disease at the community level. By mid-March 2021, only 1% of contacts developed the disease as monitored through the network of contact tracing teams and Go.Data, an IT platform for field- level case investigation and contact data collection and management. CHDSOs worked with community partners, to review deaths and ensure the surveillance system was not missing any deaths. In addition to regular COVID-19 situation updates of Cox’s Bazar District issued by the Civil Surgeon’s office, WHO supported timely dissemination of relevant epidemiological information for operational decision-making through weekly Situation Reports released on its website as well as the launch of a COVID-19 Dashboard to inform key public health information in real-time. Laboratory services. Established in 2018, with support from WHO prior to the COVID-19 pandemic, the IEDCR Field laboratory in Cox’s Bazar Medical College is a level 2 Biosafety laboratory. On 02 April 2021, it conducted the first RT PCR test for COVID-19 with an initial testing capacity of 30 samples per day for the refugee population. WHO supported the rapid scale-up of capacity with procurement of two additional PCR machines, test kits, supplies and recruitment of human resources. Within four months, the daily laboratory testing capacity rose to 500 samples and currently, it maintains a capacity of 1500 tests per day with a result turnaround time of 24–28 hours in conformance with global standards. By end of 2020, over 85 000 samples were tested through this laboratory. With existent PCR capacity, the use of GeneXpert and or Rapid Diagnostic tests have yet to be introduced owing to the comparative advantages of RT-PRC testing. The testing rate at end of March 2021 was maintained at 99 tests per 100 000 in the refugee camps which is comparable to 83 tests per 100 000 for the host population in Cox’s Bazar. Case management. Modelling studies warned that existing treatment capacities in Rohingya refugee camps would quickly be overwhelmed as patients requiring hospitalization could escalate. Under the coordination of WHO, 14 SARI Isolation and Treatment Centres (ITC) were established by health partners with a bed capacity of 1200, including the provision of oxygen to manage severe cases. The first SARI ITC, constructed with bamboo material, within the camp and host community was operationalized in May 2020. Based on an oxygen surge plan developed by WHO, six oxygen generators, over 300 oxygen concentrators and a large number of cylinders were procured by donors and health sector partners to 145Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region ensure availability at all times. To strengthen human resource capacity in clinical case management of SARI, ToTs from SARI ITC partners were rolled out by WHO and training of over 600 staff from partner organizations and government facilities completed by end of 2020. Regular weekly specialists for operational, clinical and critical care provided online services under the surge case management working group. This was done with peer-to-peer support and knowledge exchange provided by WHO experts in Cox’s Bazar. A referral pathway for the safe transfer of critically ill patients to the only ICU at Cox’s Bazar District Sadar Hospital was strengthened through a centralized Dispatch and Response Unit (DRU). Additionally, 64 staff of various SARI ITCs were trained on Basic First Aid (BFA) and mid-level 29 SARI ITC staff on Basic Emergency Care (BEC) to ensure skilled pre-hospital emergency medical care, improved management of critically ill patients and timely referral to ICU. Infection prevention and control. In February 2020, WHO conducted IPC assessments, based on the WHO IPC Framework in health care facilities (HCFs) in Rohingya camps. Findings of the assessments gave a baseline of the IPC situation and informed the preparedness and response interventions planning including a COVID-19 IPC response plan and IPC guidance documents disseminated to all partners. These remain available and accessible on a shared online folder. To accelerate IPC education and training, a pool of 43 master trainers was created. The team trained all other health care workers (HCWs) in SARI ITCs across health care facilities in the camp, in addition to humanitarian workers and government HCWs in all eight Upazila Health Complexes (UHCs) of Cox’s Bazar within a record three months. The IPC TWG and WHO designed a contextualized user-friendly daily IPC checklist and monthly score card for operationalization of IPC activities in the SARI ITCs facilities in the Rohingya camps. This innovation improved IPC practices as scorecards triggered continuous monitoring. WHO and the IPC TWG also conducted IPC supportive supervision for non-COVID-19 HCFs once every six months and to all SARI ITCs every quarter for quality control and continuous improvement of IPC practices in the HCFs. Irrational use of PPE observed at the beginning of the pandemic due to fear of infection, was reduced due to training and regular working group meetings which emphasized reasonable use of PPE to enhance PPE availability and use based on risk assessments. Following training, hygiene practices among HCWs, patients and visitors increased which reportedly increased trust of the community in the HCFs to seek essential healthcare services for they now understood this as a measure of control of COVID-19 infection spread. Essential health services. Throughout the pandemic, effective continued provision of EHS remained the highest priority with health care facilities continuing despite operational constraints and closure of other services. WHO adapted the global operational guidance on maintaining essential services to the camp setting and issued a Plan of Action and communication to communities. The Health Sector Advisory Group (SAG) conducted supportive supervision to monitor the implementation of the guidance. A revised strategy and micro plan for Routine Immunization was developed to ensure sufficient vaccine coverage and reduce dropout rates. Also, VPD surveillance was revised to ensure timely identification of VPD outbreaks like measles that have been observed to occur during or soon after other disease outbreaks. Whereas disruption in service availability or utilization during COVID-19 is noted in a survey by the Global Health Cluster COVID-19 Task Team Survey and also documented by some studies in Rohingya camps within a limited period (April to July 2020), after which utilization of services picked up again. The end-term performance review of the Health sector 2020 found 2.77 consultations/ person/year against a target of 2/person/ year, which was set prior to the pandemic. In the complex refugee camp setting in Cox’s Bazar, quick and timely coordinated modification and setup of infrastructure for identification, confirmation, isolation, IPC, and clinical management with a robust surveillance network served as essential components of the public health strategy in response to infectious diseases. The involvement of communities in decision making played a vital role in building trust and improving health-seeking behaviours of the at-risk population. Under the leadership of GoB, joint, coordinated efforts of the donor community and humanitarian partners helped limit the impact of COVID-19 on the refugee and host communities. Dr. Kai von Harbou, Head of sub-office and Dr. Simon Kaddu Ssentamu Public Health Response Consultant both from WHO Cox’s Bazar Emergency sub-office. © W H O /B an gl ad es h Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 146 Continue to reinforce and sustain public health capacity during emergencies This was the first large-scale emergency in the SEA region after the establishment of the WHE. The complex Grade 3 emergency with geopolitical and strong humanitarian dimensions involved three levels of the Organization to mount its response. The Country Office was in charge with strong support from the Regional Office. The grading and Incident Management System clarified roles and drew on the expertise and technical support from all departments, not only WHE. The WHO ERF stresses that at the onset of all emergencies, WHO ensures that predictable levels of staff and funds are made available to the WCO. In the initial stage, staff needs to be deployed from WHO. Moving staff quickly from the Regional Office, country offices, other regions and HQ is the best way to get qualified staff on the ground as soon as possible. WHO being Cluster Lead Agency for health, the Health Cluster Coordinator has an essential role and needs to be on the ground in the initial stage for a minimum 3-6 month period. Frequent changes of health sector coordinators are inconsistent with WHO’s role as cluster lead. WHE needs to train and have a pool of potential Health Cluster Coordinators who can be deployed on short notice. The ability to draw on partners such as GOARN and Standby Partners for staff deployment remain critical but need to be well managed by the Organization to ensure that selected staff fulfills its field requirements. © W H O /B an gl ad es h WHE needs to train and have a pool of potential Health Cluster Coordinators who can be deployed on short notice. 147Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region The establishment of the WHO sub-office in Cox’s Bazar stabilized the field operation in line with a protracted emergency. The need for initial and predictable funding for a Grade 3 Emergency is critical. Sometimes lack of funds coupled with the risk aversion of the administration delays important decisions, in particular for recruitments. The ERF emphasizes WHO`s “no regrets’ policy, meaning that even if there is a realization later that less staff or funds are required, there will be no regret or blame. The large-scale outbreak of diphtheria in 2017–2018 and the COVID-19 pandemic illustrate the risks and challenges of disease outbreaks in a congested refugee setting. Effective collaboration with local and national health authorities and local and international health partners is key to managing these outbreaks. For WHO, it also requires that expertise can be drawn upon from all levels of the Organization. Finally, strengthening of local public health infrastructure such as support for IEDCR Field laboratory in the Cox’s Bazar Medical College, originally done as part of the diphtheria outbreak, proved useful both for the local community and refugee camps during the pandemic. Emergencies provide an opportunity to reinforce and sustain public health capacity in the area and these must remain ongoing efforts to be further upgraded with training and use of the latest technologies. Review and evaluations are an integral component of all WHO Graded emergencies and these should be done in a transparent manner. © W H O /B an gl ad es h Effective collaboration with local and national health authorities and local and international health partners is key to managing these outbreaks.

11 C H A P T E R Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 150 © W H O /S EA RO 151Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region LEARNINGS FROM THE PANDEMIC: MAINSTREAMING HEALTH OF MIGRANTS IN HEALTH AND MIGRATION POLICIES Migrants face obstacles in accessing essential health care due to irregular immigration status, language barriers, lack of migrant-inclusive health policies and inaccessibility of services. Disparities impact their and host community’s well-being, undermining the realization of global health goals, such as UHC, reproductive, maternal, nutrition, child and adolescent health and preventing (RMNCHA) and treatment of TB and HIV. The COVID-19 pandemic highlighted them as a vulnerable occupational group since being on the move makes them easy carriers of infections and viruses across borders. Access to health care for migrants is, therefore, a major health security issue that needs not just national but cross-border collaboration. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 152 T oday, more people are on the move than ever before. As of 2019, there were close to 272 million international migrants (UNDESA, 2019) and an estimated 740 million internal migrants (IOM). Many people move across borders for shorter periods, including in an undocumented manner, going largely unrecorded by migration tracking systems. This gets exacerbated during natural disasters like floods, droughts, earthquakes, conflicts and epidemics. Many migrants are working in the informal sector, on construction sites, in factories, markets and the fishing industry. Their employers often provide accommodation in temporary or semi-permanent quarters that tend to be, characterized by congestion and inadequate sanitary facilities. Migration trends in the Region The WHO SEA Region is a dynamic region, with a large number of migrant workers who move within and between the Region and the rest of the world. An estimated 40 million South Asians work overseas, mainly in the Middle East countries, A growing trend has been a large number of women too who are going abroad independently. Together, their and sending remittances back home remains a vital part of the economy since their jobs. © W H O /D er m ot T at lo w 153Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Among countries of the ASEAN, migration has continued to grow, and the ASEAN Economic Community promotes the free mobility of professionals and skilled workers within the region. The mobility of workers is perceived as an important part of economic integration in ASEAN. Migrants from Cambodia, Lao PDR, and Myanmar head to Thailand to work in agriculture, domestic work, construction, and manufacturing. Indonesian migrants go to Malaysia and Singapore for agricultural and domestic work. In 2019, there were an estimated 12.1 million international migrants in the WHO SEA Region (UNDESA 2019). A major migration characteristic unique in this scenario is that countries in the Region can no longer be compartmentalized as either source or destination countries. For example, India is among the top 10 countries of destination for migration within the Region but also one of the top 10 countries from where migrants originate. Moreover, India, Bangladesh, Indonesia and Myanmar are among the top 20 origin countries in 2019. The Region has witnessed large-scale migrant workers or economic migrants who seek employment and serve both as exporters and users of foreign labour. It is one of the regions with the highest rates of population mobility in the world, largely due to workers’ migration. This has created its own set of challenges which has come to the forefront during the COVID-19 pandemic. Migrant workers from countries such as Bangladesh, India, Indonesia, Myanmar and the Philippines play a vital role in the agriculture, livestock, seafood, manufacturing, hospitality and other sectors in Malaysia, Singapore and Thailand. However, although majority of migrant workers now enter the host country legally, illegal migrants are a cause of concern, more so during a pandemic like COVID-19 where as authorities have limited control over undocumented workers. © W H O In di a/ D is ha F ou nd at io n Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 154 Global and regional commitments to migrant’s health Despite the 1963 Vienna Convention on Consular Relations which mandates the host country to be responsible for ensuring the safety and welfare of all individuals in their territory in times of crisis, whatever their legal status (documented or undocumented) and qualification, not all countries are signatories. The 2015 Sendai Framework for DRR explicitly recognizes migrants as key stakeholders for DRR policies and operations across levels. The need to develop mechanisms and measures to protect and assist them in emergencies has continued to be a major concern. In recent years, a number of calls have gone out to ensure that the effect of crises on migrants are adequately addressed. Since 2011, there have been discussions at the United Nations, the IOM and the High-level Dialogue on International Migration and Development on how countries can collaborate to develop a better approach to address the issue. This includes improved protection and assistance in the area affected by the crisis and enhanced capacity to evacuate people out of the area and if required repatriate them to their home country. Increasing efforts have been made to prioritize migrants’ rights in Asia, including a specific focus on their right to health. These include the 2007 Declaration on the Protection and Promotion of the Rights of Migrant Workers by the ASEAN; the 2011 Dhaka Declaration to promote migrant-inclusive health policies; the Colombo Statement from the High- level meeting of the Global Consultation on Migrant Health, Colombo, 23 February 2017, issued in February 2017; and The Delhi Call for Action to End TB in the WHO SEA Region by 2030 The 2010 first Global Consultation on Migrant Health in Madrid, co-organized by IOM, WHO and the Government of Spain, developed an Operational Framework for implementation of World Health Assembly Resolution WHA61.17 on the Health of Migrants. Following recommendations from the Executive Board of WHO, 12 priorities for promoting migrants’ health were developed by WHO. In February 2017, Sri Lanka together with WHO and IOM co- organized the Second Global Consultation on Migration and Health in Colombo in order to further engage with migrants’ health. It offered Member States and partners a platform to share best practices and research on the health of migrants, identify gaps, opportunities and new challenges, reach consensus on key policy strategies and benchmarks with the aim of creating a unified agenda on the health of migrants and refugees, and engage multisectoral partners to enable a policy environment for change. The Consultation succeeded in relaunching awareness of the crucial importance of including migrants in health systems and national health strategies and provided guidance to countries and international agencies to enter into a global dialogue on how to take concrete Sri Lanka: Second Global Consultation on Migration and Health in Colombo (2017) actions to advance the health of migrants. Consultation outcomes included recommendations at the national, regional and global levels, and the endorsement of the Colombo Declaration by participating Member States. By creating this important platform, Sri Lanka has taken a major step towards promoting migrants’ health within the Region. At a global level, the need for partnerships was raised as well as the need to ensure a dedicated space for health and migration issues within Global Compacts. It was also recommended to mainstream migrants across sectors and within the scope of implementation of SDGs. The need for political leadership, partnerships and mobilization of resources was raised, as well as importance of multiagency regional and global platforms for collaborative learning and sharing of lessons learnt. At a regional level, it was agreed to enhance cross- border cooperation, including communication between the country of origin and destination, partnerships to harmonize policies and practices, ensure continuity of care, and mainstream migration and health issues in labour or foreign policy. Recommendations at a regional level included maintaining commitments and advocating goals and targets globally. The 2015 Sendai Framework for DRR explicitly recognizes migrants as key stakeholders for DRR policies and operations across levels. 155Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 1. Promote health of refugees and migrants through a mix of short-term and long-term public health interventions. 2. Encourage continuity and quality of essential health care, while developing, reinforcing and implementing occupational health and safety measures. 3. Advocate mainstreaming of refugee and migrant health into global, regional and country agendas and promote refugee-sensitive and migrant- sensitive health policies and legal and social protection that covers health and well-being of refugees and migrant women, children and Priorities of the Global Action Plan 2019–2023 adolescents; gender equality and empowerment of refugees and migrant women and girls; and partnerships and intersectoral, intercountry and interagency coordination and collaboration mechanisms. 4. Enhance capacity to tackle social determinants of health and accelerate progress towards achieving SDGs including UHC and strengthen health monitoring and health information systems. 5. Support measures to improve evidence-based health communication and counter misperceptions about migrant and refugee health. In May 2017, the World Health Assembly endorsed resolution WHA70.15 on “Promoting health of refugees and migrants” urging the Member States to strengthen international cooperation to provide health-related assistance via bilateral and international support to countries hosting and receiving large populations. Furthermore, The World Health Assembly requested the Secretariat to identify best practices, experiences and lessons learned on the health of refugees and migrants in each region in order to contribute to the development of a draft global action plan on the health of refugees and migrants. The WHO Regional Office for SEA published consequently in 2018 a report on the Health of refugees and migrants: Regional situation analysis, practices, experiences, lessons learned and ways forward. (128) It documented examples of public health interventions and practices from countries in the Region. The inability of policies and strategies to be adaptive to the global migratory context is one of the key challenges with regard to access to health care. A major shortcoming has related to the lack of comprehensive national health policies and strategies for migrants in many SEA countries. While migration policies existed in some countries, there has been no focus on internal migrants. The lack of disaggregated data in health information systems has been a challenge in the region. Except for a few countries in the Region, data that permitted analysis of the main health issues are not available for migrants or those directly related to migration and displacement. This lack of disaggregated data hampers efforts to fully understand the extent of their health challenges and develop evidence-informed health policies. A draft Global Action Plan was endorsed at the Seventy-Second World Health Assembly to improve the health of migrants and refugees, 2019–2023. The Plan priorities encompass quality health care, occupational health and safety, mental health, public health, and social determinants of health. The plan emphasises the continuity of care from migrants' domestic conditions, through to their journey, and in their host countries. The Global Action Plan advocates for migrants' health rights, including gender and cultural sensitivity. WHO will support Member States on cross-border collaboration, data gathering and health policy. Importantly, the Global Action Plan provides a mandate for WHO to demonstrate global leadership on the health of migrants and refugees partnering with the ILO and UNHCR. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 156 Access to health services Migrants pose additional challenges to countries struggling to cope with day-to- day demands on their health systems. Migrants encounter obstacles in accessing quality health care since the provision of health services is contingent on their legal and administrative status. These glaring gaps will impact their well-being as well as that of the host communities. Pockets of unreached non-resident population groups have contributed to the failure in eliminating vaccine- preventable and other communicable diseases. Targeted health services designed for migrants and innovative financing of revenues generated by migrants have not been meaningfully deployed with flexible regulations. As a result, productive migrant populations have been perceived as a burden to the country rather than an asset to prevailing health services. The UCL–Lancet Commission on “Migration and Health: the health of a world on the move” highlighted that “migrants have a right to health and UHC is a key strategy for the realization of that right”.(129) Making UHC truly universal will promote SDG 3.8, which recommends “financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”. Creating such systems that integrate migrant populations will benefit entire communities with better health access for all and positive gains for local populations. Therefore, this coverage should be championed by politicians and health care leaders. Thailand is an upper middle-income country that has implemented UHC. In April 2021, there were about 2,3 million registered migrant workers and an estimated 2 million plus undocumented migrant workers from Myanmar, Lao PDR and Cambodia. True UHC cannot be achieved without inclusion of migrants. Thailand sought to enhance migrant health coverage, including development of migrant health policies/programmes, bilateral migrant worker agreements and migrant health insurance schemes. Currently, Thailand is perhaps one of few countries in the world that extends health coverage to undocumented migrant workers. Regular migrants (labour migrants in Thailand) are covered by the National Social Security Scheme (SSS). Thailand introduced a Compulsory Migrant Health Insurance Scheme (CMHI) for documented and undocumented migrants and their dependents working in the informal sector under the aegis of the MoPH. The benefits package of CMHI is similar to that of the UHC scheme for Thai people which enrols regular migrant workers following pre-employment health screening. Health services are available only at the hospital where the migrant was registered, and some services are available to Thai citizens which are not accessible to migrants. Thailand has also established specific policies/ programmes to address migrant health, including the Migrant Health Programme. They focus on, but are not limited to, international labour migrants and seek to strengthen migrant sensitivity of existing health services Thailand: Providing Universal Health Coverage for migrants and develop migrant friendly health services. Thailand has allowed undocumented migrant workers from Cambodia, Laos and Myanmar to stay and work legally in the country as a special case during the COVID-19 outbreak. In June 2021, out of 2 174 283 registered migrants, only 909 000 migrants (41.8%) were registered for health insurance. Thailand established policies and good practices relating to health services for irregular migrants. As of 2021, migrant health insurance is 730 Thai Baht (US$24) for a migrant child and 3200 Thai Baht (US$106) for a migrant adult for 2 years. A major lesson learnt relates to the local health budget that is allocated based on the number of patients registered. Although all migrant workers have the right to access health services, about 60% of migrant workers are not registered but avail services of primary care units (PCUs), even as the budget does not take their presence into account. This results in shortage of funding to provide all services required for PCUs. Other barriers include the scheme’s uptake, including annual fees, lack of awareness of the scheme among irregular migrants and reluctance of hospitals to promote and implement the policy. It is therefore no surprise that there is great variability in capacity of health care systems in the Region to address migrant health. Thailand has demonstrated good capacity in this regard and signed an MoU with Cambodia, Myanmar and Lao People’s Democratic Republic, providing support for health service access to migrants. Productive migrant populations have been perceived as a burden to the country rather than an asset to prevailing health services. 157Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region A comparative study carried out by the Asia Pacific Observatory on Health Systems and Policies analyzed to what extent two middle-income countries, Thailand and Malaysia, have culturally competent, migrant-inclusive health systems. (130) Malaysia has not implemented migrant-friendly services in policy or practice in MoH hospitals or clinics. On the other hand, migrant- friendly services are an established concept and practice in Thailand’s MoPH facilities. Thailand has created formal interpreter and migrant community educator schemes, known as the migrant health worker and migrant health volunteer programmes. The study emphasized the need to explicitly consider migrants when designing systems improvements in cultural competency. Interpreters were identified as the major cultural competency intervention in both countries. Moreover, migrant health policies require intersectoral thinking and applying of systems thinking in migrant health that can help identify the adverse consequences of well-intentioned policies. The study showed that it is clear that there is no one size fits all solution, and that different policy options can be considered, depending on where countries lie along the path towards achieving a truly migrant-inclusive UHC. Migrant health policies require intersectoral thinking and applying systems thinking in migrant health that can help identify the adverse consequences of well-intentioned policies. © W H O /P lo y Ph ut ph en g Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 158 The WHO and United Nations High Commissioner for Refugees (UNHCR) recently signed a new agreement to strengthen and advance public health services for millions of forcibly displaced people around the world. They will work to ensure preparedness, prevention and public health response measures to not just COVID-19 but also beyond as they reach refugees, asylum seekers, internally displaced people and those who are stateless. The Joint United Nations Initiative on Migration and Health in Asia (JUNIMA) is a regional, multi- sector coordination mechanism that contributes towards regional health security by bringing together Partnerships & interagency coordination governments, civil society organizations, regional associations, development partners and UN agencies to effectively advocate, promote policies, build partnerships, share information and support action on the right to health and access to communicable disease prevention, treatment, care and support services for migrant populations in Asia. WHO Regional Office for SEA is the co-chair while IOM is the secretariat of JUNIMA. They will together work with migrants and their families to provide equal access to health care throughout the migration process and support them to live healthy and productive lives. Public health interventions by Member States in the Region Disease Commitments made by WHO Member states Tuberculosis The Delhi Call for Action signed during the Ministerial Meeting towards ending TB in SEA in March 2017, recognized the need for TB control among migrants as an important component of the End TB strategy. Malaria In November 2017, ministers of health of all Member States adopted the Ministerial Declaration on Accelerating and Sustaining Malaria Elimination. They pledged to ensure universal access to quality-assured prompt diagnosis and treatment and effective prevention to all vulnerable and at-risk populations including refugees and migrants. Access to malaria interventions by migrants was further expanded in September 2018. Countries of Greater Mekong Subregion adopted in May 2018, the Ministerial Call for Action to Eliminate Malaria before 2030 and committed to providing services to indigenous, mobile and migrant populations as part of a larger cross-border collaboration. HIV-AIDS National AIDS strategies/programmes were adopted by Member states to reach migrant populations with effective HIV prevention, treatment, care and support services. Thailand was the first country with a large-scale HIV epidemic to achieve elimination of MTCT by offering PMCT services to all people, irrespective of their migrant status. Later, this good practice was evident in PMTCT achievement in Sri Lanka and Maldives. Neglected tropical diseases Regional Programme Review Group (RPRG) recommended lymphatic filariasis (LF) surveillance to migrant communities to look into possibilities of resurgence through migrants coming from endemic countries to countries that eliminated the disease Noncommunicable diseases Migrant health is being included in regional NCD prevention and control plans as well as regional oral health strategies. Immunization To ensure migrant communities are vaccinated through a focused intervention and routine and supplementary immunization activities as part of VPD control strategies in countries and the Region. Surveillance of VPDs among migrants and refugees is being undertaken as part of an overall immunization strategy. Polio eradication efforts in the WHO SEA Region have been seen. Notable has been India’s targeted strategy that helped identify, map and vaccinate 400 000 migrants. In Cox’s Bazar, large scale immunization campaigns were conducted to protect the target population from life threatening diseases such as diphtheria, pertussis, tetanus, polio, measles, rubella, cholera, etc. They prevented excess mortality among the refugee population. Indonesia provided Routine Immunization services free of cost to all migrants/refugee children. Bhutan has made it mandatory to vaccinate migrants and imported labourers. Mental health The WHO SEA Region collaborative framework for coordinated response to Mental Health and Psychosocial support in emergencies was published in June 2020 addressing mental health services for all vulnerable populations including migrants and refugees. 159Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region COVID-19 exposes the fragility of ecosystems inhabited by migrants When COVID struck in December 2019, migrants’ host countries experienced acute crises, given that migrant populations had few means to ensure their own safety and were one of the first to get impacted. Announcement of lockdown measures at short notice left millions of migrants unemployed and evicted from homes. Many migrant workers were forced to return to their home countries earlier than planned because of job losses or fear of contracting COVID-19 in the host nations. Horrific images and heartrending stories emerged as stranded migrants walked for days at the end without food and money to wind their way back home, placing their own lives and those of their families/villages at risk. But the economic fallout from the pandemic means that many migrant workers are likely to be without jobs for a long time. Countries in the region, therefore, tried to repatriate thousands of migrants stuck abroad without work. Relief flights were organized to repatriate them and helplines operationalized to address queries of overseas migrants. But such mass movements of people raised concerns about the risk of spreading COVID-19 infections. Many governments, therefore, rushed to stall their movement fearing the spread of the pandemic. The majority of the initial COVID-19 cases in Nepal originated in returning migrant workers, contributing to the spread to communities in border provinces. Temporary shelters and quarantine homes and hotels were set up to house migrants and screen and isolate them if required. WHO issued ‘Interim guidance on Preparedness, prevention and control of coronavirus disease (COVID-19) for refugees and migrants in non-camp settings’ on 17 April 2020. WHO issued ‘Interim guidance on Preparedness, prevention and control of coronavirus disease (COVID-19) for refugees and migrants in non-camp settings’ on 17 April 2020. © W H O Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 160 Experiences from the pandemic drew attention to the urgent need to recognize migrants’ access to health care and their living conditions which if left unaddressed posed a serious public health risk. The vulnerability of low- income migrants to COVID-19 transmission stemmed largely from their limited access to health care, often communal living in high-density and unhygienic dormitory settings and a lack of inclusive protection systems, public education and outreach. It exposed their cramped and unhygienic conditions of living marked by shared rooming houses, lack of access to water and employment. in construction, factories, street vending, domestic labour and contractual temporary jobs. Several outbreaks in factories, production plants and seafood markets staffed primarily by migrant workers have been reported during the third wave of COVID-19 in Thailand. The Government of Thailand, therefore, announced that it would allow undocumented migrant workers from Cambodia, Laos and Myanmar to work in the country legally for about two years to curb the spread of COVID-19. The Supreme Court of Nepal for instance issued interim orders to rescue vulnerable migrants and allowed foreign nationals to stay on in the country and made available UHC to all migrants, regardless of their legal status. © W H O /S EA RO It exposed their cramped and unhygienic conditions of living marked by shared rooming houses, lack of access to water and employment. 161Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Mapping the way forward Universal and equitable access to health services within the scope of UHC needs to be provided by the Member States to migrants, regardless of age, gender or legal status. This should be embedded in national migration and health policies in line with accepted international norms and standards. Measures need to be taken to overcome language and culture barriers for migrant workers and their families in accessing health care. Special consideration will need to be taken for migrants and the moving population during disasters and emergency situations. Reduce migrants’ specific vulnerabilities. Migrant workers will likely continue to be an important part of the economic development both for the host country and their home countries, also in the post-pandemic period. But the public health risks related to sub-standard and congested working and living conditions have been demonstrated during the pandemic. The ‘new normal’ therefore has to include minimum standards in the working environment and living conditions for temporary and migrant workers. This includes development, reinforcement and implementation of occupational health and safety measures and ensure migrant workers enjoy the same level of health and safety protection at work like all other workers, including living quarters, working hours, rest and recuperation. International Labour Standards provide protection to all workers, irrespective of migrant status, from sickness, disease and injury arising from their employment. Prevent stigma and discrimination. Migrants may face stigma and discrimination as they often are not well integrated into the local communities and be stigmatized because of cultural and religious differences. Accurate evidence- based information should be provided on the possible impact of COVID-19 outbreaks among migrant and host communities. This information should seek to dispel fears and misperceptions among host populations regarding migrants and COVID-19 outbreaks. Foreigners are often wrongly seen as the cause of the disease or ones who brought the disease to the country or community. Education of the public through media and other communication channels and engagement of communities are needed to limit stigma and discrimination Managing safe repatriation of refugees and migrants at PoE. During a public health crisis like the pandemic, several aspects need to be considered where migrants are concerned. Standards for the safe operation of quarantine facilities, minimizing risks of those living in border areas, providing temporary permission to stay and work in the host country including for undocumented migrants must be available and communicated at the earliest. Call for greater cross-border collaboration. Porous borders, multiple legal/illegal crossing points and high population movement has contributed to the haphazard treatment of migrants. Countries must have standardized protocols with respect to surveillance standards, risk perceptions and response models, keeping the issues of migrants and refugees in mind. Health monitoring with disaggregated data for health-seeking behaviour of migrants. Surveillance of the health of refugees and migrants must be part of the overall national health surveillance. Rights-based approach towards social determinants of health. Factors such as migration process, reasons for migrating, mode of travel, length of stay, migrants’ language skills and social and legal status in destination countries have a bearing on their health profiles. Migrants who get lured into trafficking and low-skilled irregular work are more vulnerable to violence and exploitation which can impact their physical, mental and sexual health. Measures need to be taken to overcome language and culture barriers for migrant workers and their families in accessing health care.

12 C H A P T E R Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 164 © W H O 165Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region ESTABLISHING WHO HEALTH EMERGENCY PROGRAM (WHE) TO STRENGTHEN TECHNICAL AND OPERATIONAL CAPACITIES The WHE programme requires different levels of organizational hierarchy – from HQ down to regional and country office levels to work with clear structures and processes. It cuts across international, regional and country-level programmes to deploy resources quickly when emergencies strike, establishing lines of leadership and responsibility. The programme is tasked with helping countries prepare for health emergencies and disasters while providing support to recovering even as a new organization-wide policy framework for responding to health emergencies and recruiting of new specialized personnel is adopted. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 166 E mergencies by nature are meant to be chaotic and unpredictable. Between 2011 and 2016, WHO reported over 1000 epidemics across 168 countries. Public health crises such as the 2004 Indian Ocean Tsunami, the 2009 H1N1 pandemic, the 2014 Ebola virus disease outbreak in West Africa, the 2015 Nepal earthquake and the COVID-19 pandemic have all highlighted global risks of infectious disease outbreaks while demonstrating the need for more effective international collaboration on health security and pandemic preparedness. Convergence between disease risk and humanitarian need has become increasingly evident with outbreaks turning into humanitarian emergencies and humanitarian emergencies often getting complicated by outbreaks. (131) Global consensus for a dedicated health emergency programme Since 2001, the WHO has been promoting its ability to manage global health security and undertake extensive reform. Countries have been encouraged to strengthen their pandemic preparedness while WHO released a series of guideline documents detailing measures to achieve objectives related to building vaccine manufacturing capacities, stockpiling antiviral medications, developing national emergency committees, etc. These guidelines brought with them templates and frameworks for how and when WHO could declare certain events as pandemics or PHEICs, outlining multiple stages and inflexion points or ‘phases’, from ‘limited human-to-human transmission’ to widespread and sustained community-level infection. (132) © W H O /S EA RO 167Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region In 2015, the Executive Board at its Special Session on Ebola Emergency made numerous requests of the Director-General involving undertaking of wide- ranging reforms in WHO’s work related to outbreaks, humanitarian emergencies and crises. These reforms were to be guided by an Ebola Interim Assessment Panel, a Director-General’s Advisory Group on Reform of WHO’s Work in Outbreaks and Emergencies with Health and Humanitarian Consequences and a Review Committee on the Role of the IHR (2005) in Ebola Outbreak and Response. The reform of WHO’s work in emergencies was later aligned with the report of the United Nations Secretary-General’s High-level Panel on Global Response to Health Crises. Establishing the WHO Health Emergencies Programme From prevention through preparedness to early warning, response and early recovery, the WHE programme represents a fundamental change for WHO, complementing its traditional technical and normative capacities with new operational capabilities to enable it to work across the breadth of the emergency-management cycle in outbreaks and humanitarian emergencies. WHO’s task was cut out as it helped countries prepare, prevent, respond and recover from emergencies caused by disease outbreaks, disasters or conflicts. The collective push by countries, other agencies and partners led to a final decision being taken at the Seventy-Third World Health Assembly (WHA) with a mandate to improve operational capacities and capabilities of organizations so that WHO could effectively and efficiently respond to outbreaks and health emergencies. This paved the way for one of the most fundamental reforms in the shape of the launch of the WHO Health Emergency Programme (WHE) on 01 July 2016 by the then Director-General Margaret Chan.(133) Implementation and functioning of the new WHO Health Emergencies Programme All WHO’s work in emergencies was brought under a single programme to optimize intra-agency coordination, operations and information flow. The new Health Emergencies Programme represented a fundamental development complementing WHO’s traditional technical and normative role with new operational capacities and capabilities for its work in outbreaks and humanitarian emergencies. It was designed to bring speed and predictability to WHO’s emergency work, using the “all- hazards” approach, promoting collective action and encompassing preparedness, readiness, response and early recovery. It was aligned with the principles of a single programme, with one clear line of authority, one workforce, one budget, one set of rules and processes and one set of standard performance metrics. In the last few years, rapid progress has been made in building operational capacities to enable WHO to respond more effectively to outbreaks and emergencies. This includes the adoption of an Incident Management System (IMS) as the main organizational approach to managing the response to emergencies. The structure and SoPs for the new programme were finalized and consistent use of the new IMS ensured to coordinate response to emergencies and align WHO staff to new programme design at HQ and regional office level. Simultaneously, technical and normative support was provided to the Member States leading to a transformative process that enabled WHO to meet the immediate health needs of populations affected by crises, whilst tackling root causes of their vulnerability. A conceptual framework (Fig 1) was outlined underpinning how the new programme was geared to achieving those results.(134) This paved the way for one of the most fundamental reforms in the shape of the launch of the WHO Health Emergency Programme (WHE) on 01 July 2016 by the then Director- General Margaret Chan. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 168 FIGURE 1: Conceptual framework for operationalizing the WHE programme Office of the Executive Director Prevention Preparedness Early warning, response and early recovery Communications (COE) Resource Mobilization (RMB) WHO Health Emergencies Programme External Relations (EXR) High-threat pathogens (PAT) Experts networks and interventions (ENI) Infectious hazards management (IHM) PIP secretariat (PIP) Core capacity assessment monitoring and evaluation (CME) Preparedness, readiness and core capacity building (PCB) IHR secretariat and global functions (IHR) Detection, verification, and risk assessment (DVA) Health ops monitoring and data collection (MDC) Data management analytics and products (MAP) Humanitarian policy and guidance (HPG) Emergency management and support (OPM) Operational partnerships (OPR) Operational support and logistics (OSL) Work planning budgets and finance (WBF) HR, security and staff wellbeing (HSW) Grant management and reporting (GMR) Continuous business improvement (CBI) Country health emergency preparedness and IHR (CPI) Health emergency information and risk assessment (HIM) Emergency operations (EMO) Management and administration (MGA) Led by the office of the Executive Director, WHE has five technical and operational departments (136), namely: i. Infectious hazards management. This includes high threat pathogens, expert networks and, at HQ, the secretariat of the Pandemic Influenza Preparedness Framework. ii. Country health emergency preparedness and the IHR (2005) core capacity building. This includes monitoring and evaluation of national preparedness capacities, planning and capacity building for critical capacities and, at HQ, the secretariat of IHR (2005). iii. Health emergency information and risk assessments. This includes event detection and verification, health emergency operations monitoring, and data management and analytics. iv. Emergency operations unit. This includes incident management functions, operational partnerships and readiness and operations support and logistics. The unit aims to make sure populations have access to an essential package of life-saving health services during any given health emergency. To achieve this, WHO instituted protocols to establish a comprehensive incident management structure, supported by graded and protracted emergency desk teams, across all three levels of the Organization (HQ, regional offices, and country offices) to coordinate health emergency partners. The IMS is now in operation to manage all graded events that have occurred since WHE was established. The unit aims to make sure populations have access to an essential package of life-saving health services during any given health emergency. 169Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region v. Emergency operations management and administration and external relations. The Technical Emergency Reference Network (TERN) was approved in 2017 in response to WHA A 69/30An emergency fund for preparedness and response. Its primary goal was to use the most updated technical expertise and knowledge; leverage linkages across departments and support Member States in achieving security goals such as the IHR, Sendai Framework and the SDGs. On 29 March 2016, the Director-General established the Emergencies Oversight and Advisory Committee to provide oversight and monitoring the development and performance of WHE as also to guide Programme’s activities and report findings through the Executive Board to the Health Assembly. WHE’s Functioning in the WHO South-East Asia Region The establishment of WHE promoted an important alignment of the Organization’s work on health security and humanitarian action. WHO’s work in support of Member State preparedness was aligned with recommendations of the Review Committee on the Role of IHR (2005) in the Ebola Outbreak and Response and Sendai Framework for DRR 2015–2030. The WHE’s work in preparedness was structured to support application by all States Parties of the new monitoring and evaluation framework for the IHR (2005) and assessments with the new JEE tool as requested; and that support for national preparedness planning and capacity building would be prioritized to high- vulnerability, low- capacity countries with a focus on rapidly establishing critical core capacities for early warning, incident management, risk communications and safe hospitals. Preparedness planning and capacity building were further integrated with the Organization’s work in health systems strengthening. (135) It was with much relief that WHO SEA Region welcomed the launch of WHE, for it needed a dedicated body to respond in the event of any outbreak, conflict or disaster strike. The new WHE’s main functions are to provide a platform for cooperation and collaboration during emergencies; encourage two-way discussions; and facilitate development, implementation and M&E in emergencies. Priority actions for the Regional Office for SEA are outlined and include finalization of a priority plan for countries and regional action; strengthening partnership for DRR, emergency preparedness and response (EPR) and global initiatives; capacity building for the Member States; institutionalizing of IMS; supporting regional platforms for a response such as ASEAN; strengthening health emergency logistics; and developing IPC and disease-specific regional networks. Technical and operational support is provided from other levels of the Organization to country-level operations for graded emergencies managed through the following mechanisms: Revision of Emergency Response Framework (ERF) to manage the crisis better The development of the WHO ERF in 2017 was an important milestone in providing clear guidance and policy for the WHO Offices in the effective and efficient management of health emergency operations with specified performance standards and indicators. The ERF deals with WHO’s response to emergencies even as WHO supports the Member States to build capacities to manage risks of outbreaks and emergencies with health consequences. When national capacities are exceeded, WHO assists in leading and coordinating the international health response to contain outbreaks and provide effective relief and recovery to the affected population. WHO ERF was revised to serve as a single, common, all-hazards set of emergency management processes for WHO’s work in organizational readiness, risk assessment and response. The WHE was designed to address all hazards, flexibly, rapidly and responsively with a bold vision that put countries at the centre of its work, to better protect one billion more people from health emergencies. It works with other WHO programmes and partners to address the full cycle of health emergency preparedness, response and recovery. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 170 Grading protracted emergencies: Any situation where ongoing humanitarian needs in a country are addressed through an IASC Humanitarian Response Plan (HRP) or equivalent are graded as a protracted emergency (Fig 2). The grading triggers activation of WHO’s Incident Management System providing a standardized, yet flexible approach to managing its response to the emergency. WHO applies the IMS regardless of the underlying hazard/scale/operational context of the emergency. The main purpose of WHO’s protracted grades is to indicate the level of operational response to be sustained by WHO over a prolonged, often indefinite period. They help communicate to external stakeholders WHO’s assessment of the need for sustained international resources in the health sector to assist affected communities. New, standard processes were developed for risk assessments, grading of events and incident management. All major infectious risks and major emergencies with health consequences are assessed and/or graded by WHO and are closely aligned with processes in use by the wider humanitarian and crisis management system. Post this, the Executive Director submits outcomes of all major risk assessments and event gradings to the Director-General within 24 hours for decisions on grade, incident management and leadership in consultation with Regional Directors. The single IMS is improving the predictability and interoperability of WHO response activities. (136) Support at regional level: An Emergency Coordinator and Incident Management Support Team (IMST) is appointed at Regional Office for all graded emergencies, within 24 hours of grading. The size and composition of IMST varies according to grade of the emergency. Support at HQ and Organization level: Emergency Officer and IMST are appointed at HQ for all graded emergencies. For most emergencies, they work through Regional Office to coordinate HQ level and Organization- How WHE supports different cadres and levels of the Organization wide support. On occasion, WHE Executive Director and WHO Regional-Director may agree to coordinate all country-level support for a specific emergency from HQ. For protracted emergencies: An Emergency Coordinator is appointed at the Regional Office for all protracted emergencies and an Emergency Officer at the HQ Office for protracted grades 2 and 3. Also a Country Support Team is appointed at the Regional Office and a Regional Support Team at HQ. FIGURE 2: WHO levels for graded emergencies Grade assigned to the emergency Nature of emergency A public health event or emergency monitored by WHO but does not require a WHO operational response. A single country emergency requiring limited response by WHO. The response still, exceed the usual country-level cooperation which that WHO Country Office (WCO) has with the Member States. A single country or multiple country emergency, requiring moderate response by WHO. Level of response required by WHO always exceeds the capacity of WCO. A single country or multiple country emergency, requiring major/maximal WHO response. For events/ emergencies involving multiple regions, an Incident Management Support Team at HQ coordinates response across regions. Source: Emergency reform framework, second edition, WHO, 2017 UNGRADED GRADE01 GRADE02 GRADE03 171Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Activation of the Incident Management System: Within 24 hours of grading acute emergencies, WHO ensures safety and security of all staff; appoints an Incident Manager in-country for a minimum of three months; activates emergency SoPs, and establishes an initial Incident Management Team (IMT) in-country to cover the six critical IMS functions. This is done initially by repurposing country office staff. Also, an Emergency Coordinator and Incident Management Support Team (IMST) is appointed at regional/ HQ levels to coordinate Organization-wide support for response to Grades 2 and 3 emergencies. A focal point is appointed at regional and HQ levels for Grade 1 emergencies to coordinate any required support. However, flexibility may be required, especially for emergencies for which high levels of insecurity do not permit the in-country presence of international staff. In such cases, elements of IMT may be located in a neighbouring/nearby country, providing remote support for in-country IMT members. Recognizing the importance of rapid, accurate and objective assessments of risks that are of potentially high consequence, the Programme, under the Executive Director, initiates within 72 hours an on-the-ground assessment when notified of a high threat, clusters of unexplained deaths in high- vulnerability/ low-capacity settings and other events deemed appropriate at the discretion of the Director-General. Outcomes of such risk assessments are shared with the Member States through their NFPs for IHR (2005), or other channels, the United Nations Inter-Agency Standing Committee and WHO Emergencies Oversight and Advisory Committee. A standing interdepartmental task force at HQ and regional office levels enable the programme to harness the broad range of expertise across WHO’s technical programmes and networks, particularly for research and development, policy, capacity building for preparedness, health systems strengthening, and protracted crisis planning and programming. These linkages are operationalized through mechanisms such as the WHO blueprint for accelerating research and development in epidemics or health emergency situations. WHO Representatives and country offices are assigned important responsibilities for implementing and facilitating activities of the Health Emergencies Programme, with their performance measured against standardized indicators. For large-scale events that overstretch national capacities, the WHO Global Emergency Medical Team initiative is ensuring that international, independently verified teams are available to respond. Within the Emergency Operations unit, the Operational Support and Logistics team ensures that essential logistics are established and emergency supplies distributed to points of service. © W H O /N ep al Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 172 In high-vulnerability, low-capacity countries, WHO offices have dedicated staff to support the Member States with their work in “all-hazards” preparedness and response capacity building. In settings of protracted crises, WHO strengthens its in-country leadership, ensuring that, over time, all WHO Representatives receive the training given to Humanitarian Coordinators. Where health clusters have been activated, priority is given to deploying long-term, properly trained Health Cluster Coordinators with sufficient staff to fulfil core cluster functions. For large- scale emergencies and high-risk outbreaks, an Incident Manager and team are appointed and deployed to complement the capacities of the Representative and country team. Since the EMT verification process was launched in July 2015, almost 100 organizations and teams have applied to be listed and independently verified as capable responders. Teams include logistics specialists with skills to rebuild damaged hospitals, incident managers and information managers and technicians who can run mobile laboratories. WHO works closely with UNICEF, WFP and partners to ensure effective supply chain management so that medical supplies and equipment are available where required. Financing WHE and setting up of a special Contingency Fund Financing the work of the new WHE requires a combination of core financing of the Programme for baseline staff and activities at the three levels of the Organization. In order to provide a sustainable solution for closing the substantial financing gap for WHE, additional voluntary contributions will be required and ideally combined with additional assessed contributions, in keeping with the expansion of WHO’s mandate to include a substantive operational role in emergencies. In 2019, a regional resource mobilization strategy was also developed to keep mobilizing funding and other resources through regular interactions with the donor community and partners’ organization. WHO works closely with UNICEF, WFP and partners to ensure effective supply chain management so that medical supplies and equipment are available where required. © W H O /S EA RO 173Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Historically, the programme has faced chronic budget and human resource shortages, relying heavily on appeals and voluntary contributions to supplement available budgets. The WHO Contingency Fund for Emergencies (CFE) was developed for WHE to rapidly access the resources needed in order to initiate response operations, rather than risk delay while waiting for other funding mechanisms to mobilize necessary resources. Funding from this mechanism can be released in as little as 24 hours and utilized for a variety of necessary operations, including rapidly deploying technical experts to the field, purchasing vaccines and other medical countermeasures, and coordinating the distribution of medicines. Contributions to the CFE are not earmarked for specific activities, thus allowing WHO the flexibility necessary to respond to a broad array of emergencies with different needs and priorities. This requires full financing of the WHO Contingency Fund for Emergencies to enable it to rapidly initiate operations in acute emergencies and crisis-specific financing for activities in protracted crises. In addition, the South-East Asia Regional Health Emergency Fund (SEARHEF) is also used to disburse funds in public health emergencies in the Region but has fewer funds available compared to CFE. The SEARHEF was planned and implemented in 2008 in the Region as an operational fund, providing support to the health sector response of Member States during disaster and health emergencies. Established under the Regional Committee resolution SEA/RC60/R7/2008 by pooling a budget of US$ 1 million for each biennium from Assessed Contributions. The Fund complements the Regional Flagship Priority on scaling up emergency risk management capacity in the SEA Region. The Sixty-ninth session of the WHO Regional Committee for SEA endorsed resolution SEA/RC69/R6 on “Expanding the scope of SEARHEF” to include a “preparedness stream” to strengthen key aspects such as disease surveillance, health emergency workforce and health emergency teams. The purpose of the fund for preparedness is to complement, not replace, development programmes under the biennium workplans. From the total of US$ 400 000 in Voluntary Contributions made by Thailand and India, US$ 125 000 has been disbursed to Bhutan (US$ 50 000), Maldives (US$ 50 000) and Sri Lanka (US$ 25 000), for strengthening HEOCs and rapid response teams or for surveillance, etc. The HEOCs in all three countries of Bhutan, Maldives and Sri Lanka have been operationalized as part of the incident management system for the COVID-19 pandemic response. Management of the preparedness stream of SEARHEF is overseen by the same Working Group comprising representatives from all 11 Member States that manages the response stream. The Working Group has met ten times since 2008. The CFE rapidly disburses funds to initiate initial emergency response even as funds through routine channels get approved/sanctioned/disbursed. This special fund has revolutionized what countries do in providing an immediate infusion of funds into the system. The Fund has come to the rescue of countries as they respond to public health events of international emergency with immediateness. It is one of the fastest single contingency funds in the world with respect to responsiveness time. The WHE called for a combination of core financing for WHO normative work, a contingency fund for rapidly initiating and scaling up emergency response operations and ongoing appeals to support operations and crises from the Member States, international organizations, regional institutions, NGOs and philanthropic agencies. To support its role in coordinating a global response to public health emergencies, WHO established the contingency fund with a target capitalization of US$ 100 million. Financed through voluntary contributions, it supports all aspects of WHO’s emergency response work, including mobilization of a global health emergency workforce and surveillance in high-risk areas. The global funding mechanisms such as CFE, CERF and the regional mechanism unique to the Region (SEARHEF) have facilitated timely, effective and efficient emergency response through the Incident Management System under the guidance derived from the WHO Emergency Response Framework. To support its role in coordinating a global response to public health emergencies, WHO established the contingency fund with a target capitalization of US$ 100 million Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 174 Another funding mechanism used regularly for health and humanitarian emergencies is the United Nations Central Emergency Response Fund (CERF), which was established in 2005. It has the ability to rapidly release resources to WHO to supplement funding requirements for response operations. In terms of overall country operations, given the capacities and operational strength of the Government, WCO functions were not always operational and more upstream and technical, even during response. Through the Asia Pacific Strategy for Emerging Diseases and Public Health Emergencies (APSED III), core capacities required by IHR (2005) are now being advanced, providing an important foundation for pandemic preparedness. This is complemented by efforts to strengthen disease-specific systems and capacities, including for vaccines, pharmaceuticals and other public health interventions. Meanwhile, countries are being encouraged to engage whole-of-society for effective pandemic preparedness and response. The raised awareness among the Member States about the health risks, hazards and vulnerabilities identification and mobilization of funding and other scarce resources while increasing engagement of operational partners is paving the way for further strengthening emergency preparedness, operational readiness and response in the Region. Distinguishing features of WHE in the context of the South-East Asia Region Strengthening partnerships. For all graded and protracted emergencies WHO develops a strategic response and joint operations plan with national authorities and partners. Some of the networks and partners that are key to WHE’s work include: Central Emergency Response Fund (CERF) has the ability to rapidly release resources to WHO to supplement funding requirements for response operations. Global Outbreak Alert and Response Network (GOARN). Network of over 250 technical institutions responds to public health emergencies by deploying personnel and resources to affected countries and sharing technical expertise and knowledge. Global Health Cluster. Network of over 900 partners that provide technical and operational support to national health response to health and humanitarian crises. Emergency Medical Teams Initiatives. They support organizations and the Member States in strengthening their capacity and health systems through the deployment of emergency medical teams (EMTs) during outbreaks. Standby Partners Programme. Organizations that are part of the Standby Partners Programme provide WHO qualified professionals who can be rapidly mobilized for emergency operations. Emergency Committees and Public Health Emergencies of International Concern. Under the revised IHR (2005), the WHO Director-General can convene an Emergency Committee during a health emergency to provide views on whether [the] event constitutes PHEIC and make temporary recommendations to the Member States. National Influenza Centres. NICs in the Region come together to share updates on influenza viruses, identify best practices and agree on action plans to combat specific diseases. These centres share data to inform the Global Influenza Surveillance and Response System (GISRS). 175Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region WHO Indonesia established its Health Emergencies programme in 2017 by merging two units, namely Emergency and Humanitarian Action (EHA) and Disease Surveillance and Epidemiology (DSE). This major development harmonized and unified the Organization’s approach to dealing with health emergencies. The WHE provided support to MoH and other government agencies for integrating public health and pandemic influenza preparedness with the disaster management system, adapting the WHO Pandemic Risk Management guideline in the respective country's context. It provided an opportunity to advocate and support the implementation of IHR M&E framework (SPAR, JEE, Simex, AAR) across relevant programme areas of MoH and government agencies such as the Coordination Ministry of Culture and Human Development, National Disaster Management Agency, Ministry of Agriculture, Ministry of Environment, etc. The establishment of WHE in Indonesia created operational efficiencies in how emergencies are handled. Comprehensive inputs were provided to Humanitarian Country Team (HCT), for disease surveillance, outbreak response and control following natural disasters and collaboration among UN agencies and partners for mitigation, response and recovery. In-country donors were encouraged to invest financial resources towards building country capacities for health emergency preparedness. Improved coordination with emergency preparedness and the response was seen between WCO, RO and HQ. A clear incident management system was set up for an emergency response. Joint funding for emergency response and outbreak and utilization of health clusters and partners through HCT were welcome moves. The country made excellent progress on emergency preparedness in compliance with IHR 2005, including JEE How WHE in Indonesia evolved to streamline preparedness and response to emergencies of IHR core capacities in 2017. Development of the National action plan for health security (NAPHS) began soon after JEE, through multisectoral coordination and collaboration and support of a presidential instruction. The logic model approach was used to develop NAPHS, providing a robust framework to ensure activities were linked to indicators at capacity levels delineated in JEE. Development of NAPHS was done in line with the National medium-term development plan 2020–2024, which included a focus on health system strengthening based on the primary healthcare approach. An innovative approach taken in 2018 was the inclusion of emergency preparedness in the mandatory minimum service standards for provincial and district governments. These standards articulated the importance of local emergency preparedness in Indonesia’s decentralized governance through the development of contingency plans and simulation exercises for natural disasters and potential disease outbreaks. The development of NAPHS benefited from Indonesia’s extensive experience in pandemic influenza preparedness planning and exercises, integrated with a national disaster management system. A full-scale pandemic simulation exercise was held in 2017 with multisector stakeholders joining hands to strengthen pandemic preparedness. In 2009 technical support and funding on EWARS Implementation was provisioned for Event-Based Surveillance and EWARS Hospital and Laboratory in three pilot provinces in 2019. In the coming months, more streamlining is expected. The Standard EWARS reporting system for use in emergencies will be established as part of the strengthening of the health cluster. Systematic engagement with civil society and the private sector, stronger collaboration with the Ministry of Social Affairs in utilizing village funds and village structure for disasters will add more robustness to the WHE programme. The country is now looking forward to playing a leadership role in global health matters like GHSA and G20 forum. (137) Providing core services and training for emergencies. Every attempt is made by WHE to get the Member States to be effectively managed, sustainably financed and adequately staffed at all times. Human resources are trained for emergency deployment on an ongoing basis using SOPs while supporting standardized work plans. WHE programme prioritizes learning and training to meet WHO’s target of ensuring that one billion people are better protected from health emergencies. In October 2018, the Programme established a new Learning and Capacity Development unit and launched its first-ever Learning Strategy to guide all training and learning activities across the country, regional and global levels. In addition to supporting the Member States in capacity building through training (online learning resources or onsite training), WHO also supports countries in strengthening operational readiness for emergencies. Operational readiness is the capacity to respond to emergencies and disasters in a timely and effective manner. Readiness is the outcome of preparedness actions that comprise planning, allocation of resources, training and organizing to build and improve operational capabilities to manage risks and respond to emergencies resulting from all hazards, based on risk assessments and in a timely, predictable and effective manner. Operational readiness is the capacity to respond to emergencies and disasters in a timely and effective manner. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 176 The WHO Regional Office for SEA conducted a readiness training programme consisting of four modules during 2017–2018 (See Box below); involving staff from WHO country offices as well as from the regional office. This operational readiness training programme facilitated the development of business continuity plans and contingency plans in few of the Member States and improved the readiness capability of WHO staff for swift deployment in recent emergencies. The ongoing COVID-19 pandemic has made the Member States and operational partners realize greater need for strengthening operational readiness of the ministries of health, safety assessment and operational readiness of health facilities, health services delivery, supply chain system and health workforce for seasonal health emergencies and complex humanitarian situations due to concomitant hazards. The resilience of the populations and health systems of countries will be increased if DRR, emergency preparedness and response activities are supported by operational readiness measures. (138) Monitoring country emergency preparedness. Over the past decade, Member States made investments in health security guided by three generations of the Asia Pacific Strategy for Emerging Diseases and Public Health Emergencies (APSED III). WHE works with them to monitor and evaluate countries’ public health emergency preparedness and capacities to respond. Member States provide annual reports on progress in advancing core capacities under IHR 2005. The AARs are completed following outbreaks and emergencies, measuring the performance of capacities and incorporating lessons learned into emergency response plans/systems. In the absence of outbreaks or public health emergencies for review, countries conduct exercises to test response processes under simulated conditions. Also, JEE of IHR capacities is conducted by teams of internal and external experts to promote transparency and accountability. Through a combination of approaches, monitoring and evaluation of IHR implementation, countries are guided to be better prepared for outbreaks and emergencies. Training and SoP implementation in the Region The resilience of the populations and health systems of the countries of the Region will be increased if DRR, emergency preparedness and response activities are supported by operational readiness measures. JULY 2017: Readiness training held on ERF, IMS, vSHOC, WHE e-Manual and SoPs DECEMBER 2017: Readiness training held on Business Continuity Plan and Contingency Plan APRIL 2018: Readiness training held on Management, Administration, Operational Support & Logistics Because of readiness training modules, staff of WHO Regional Office for SEA and country offices got better prepared for deployment to Grade 3 emergencies around the world. They received training on different aspects of ERF and event response procedures, including incident management system. The training ensured WHE staff in WHO offices acquired higher degree of awareness of logistics and supply chain management. Emergency operations units were prepared to offer more readily and manage direct sourcing of supplies to respond to immediate needs. They ensured that, as long as budgets were available, the region maintained stocks of interagency emergency health kits, personal protective equipment kits, noncommunicable diseases kits, rapid diagnostic testing kits, antiviral drugs for influenza, and other essential emergency medicines and supplies. The trainings enhanced operational readiness not only within individual country offices but also through horizontal collaboration among them. For example, Nepal supported Bhutan in conducting training on installing medical camp kits in field camps on two occasions in 2018. The Regional Office could quickly respond to meet Member States’ need for emergency medicines and supplies in recent emergencies like (i) influenza outbreak in Myanmar in 2017 (Oseltamivir supplies), (ii) floods in India in 2018 (rapid diagnostic tests for leptospirosis) and (iii) air pollution in India in 2019 (masks for teams doing field work). The successful delivery of the training modules resulted in recommendations for further pursuing and improving operational readiness in the region. 177Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Combining technical and operational expertise. WHE performs the dual role for technical normative work coupled with the operational capacity to respond to events and emergencies. It is important to work with the premise that emergency work is not like routine programming where delays in implementation are acceptable. In emergencies, unless technical support is strengthened with healthy amount of funding the on-ground disaster/emergency response will be compromised. Important milestones achieved but a lot more needs to be done still Since its establishment in mid-2016, WHE has radically reformed the way WHO works in emergencies. This new way of working highlighted gaps in competencies of existing personnel and the urgent need to prepare an adequate surge capacity for emergency work. Going forward, the programme will continue to respond rapidly to emergencies under a coordinated incident management system. It will ensure that WHO's work in emergencies is effectively managed, sustainably financed, adequately staffed and operationally readied to fulfil its mission. It will also provide access to ehs in fragile, complex and vulnerable settings, support research and development of tools, products and interventions for high-consequence diseases and natural disasters; improve and facilitate national and international readiness to respond; assess and report all-hazards emergency capacities in countries through tools such as JEE, and strengthen emergency preparedness measures. According to an independent committee tasked with the review of its work, the WHE programme, while demonstrating progress since its establishment in 2016, still requires areas of improvement. Further, a network of global health security experts urges the organization to work towards doubling its flexible funding. So far, WHO’s budget has been reliant on voluntary contributions. But these donations are largely tied to specific programmes and issues with conditions, leaving the organization little leeway to allocate and reallocate resources. Flexible funding is received mainly in the form of assessed contributions, although it covers a small percentage of its overall budget, a challenge that has plagued the organization for years. Lack of predictable funding for the WHE programme is a critical issue that senior management in the Organization is aware of. It is amply clear that to have a fully operational Health Emergencies Programme within WHO it is important to have on board partners providing solid financial support on a sustainable basis. Given the intensity of climate change events and other emergencies, more sustainable financing mechanisms will be required. National Institutes of Health will need to be given more teeth so they can step up their strategies and sanction funds for emergency infrastructure. Progress has been made to strengthen the Global Health Emergency Workforce. The EMTs continue to join the WHO-led quality assurance process. Regular training is held communicating the latest updates and versions of WHE SoPs and e-Manuals to WHE/non-WHE staff. In future work, WHO will give priority to establishing national EMTs that can be deployed locally in high-vulnerability countries and rapidly strengthen the Health Cluster leadership and capacity in priority countries. In parallel, WHO will continue to strengthen the secretariat of GOARN while enhancing advocacy work and capacity of partners in the Response Network to systematically support WHO and the Member States in alert detection, risk assessments and rapid response activities. Every effort will be made to learn from ongoing emergencies like COVID-19 to improve existing strategies. Documenting the work of WHE will be a major task to enable Member States to learn from each other’s experience and strengthen their own WHE. It is amply clear that to have a fully operational Health Emergencies Programme within WHO it is important to have on board partners providing solid financial support on a sustainable basis.

13 C H A P T E R Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 180 © W H O /N ep al 181Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region COORDINATING OPERATIONAL SUPPORT AND LOGISTICS The mission of WHO's Health Emergencies Programme (WHE) is to help the Member States and to coordinate international action, to prevent, prepare for, detect, rapidly respond to, and recover from outbreaks and emergencies. Operations Support and Logistics (OSL) provides the delivery of a full range of logistics and operations services for emergency preparedness and response readiness and post-emergency response surge and recovery activities of the WHE. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 182 I n January 2015, the WHO Executive Board Special Session on Ebola adopted resolution EBSS3.R1 requesting the Director-General to strengthen the emergency operational capabilities of the WHO to enable it to fulfil its mandate and respond to outbreaks and emergencies on the basis of an “all- hazards” approach. Under this resolution, WHO developed the WHO Health Emergencies (WHE) Department that operated across the three levels of the Organization to deliver rapid, predictable, and comprehensive support to countries and communities as they prepared for, faced and recovered from emergencies caused by any type of hazard to human health, whether disease outbreaks, natural or man-made disasters or conflicts (Read more in Chapter 12). Today, the Operational Support & Logistics (OSL) unit is part of the Emergency Operations unit (EMO) and is the operational backbone of WHE to respond to all emergencies including natural disasters, epidemics and other health-related humanitarian crises. (139) The role of OSL in the pre-disaster, disaster and post- disaster phase includes but is not limited to assessing the needs and gaps of the country requirement in terms of operations and emergency response with essential medical supplies and kits, setting up of health facilities and related infrastructure that is safe and prepared for emergencies to protect the lives of their occupants while enabling effective health response and recovery, and protecting the public and private investments to the establishment of an incident command system during any public health emergency. Supporting logistics also includes stockpiling and prepositioning of medicines and supplies, effective supply chains and reliable transportation and telecommunications. © W H O In do ne si a/ G de Y og ad hi ta 183Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region More than 25 hospitals and 1000 health facilities were completely or partly damaged. Medical Camp Kits provide immediate relief in the 2015 Nepal Earthquake response On 25 April 2015, a 7.8 magnitude earthquake struck Nepal, followed by a subsequent shock of 7.3 magnitude on 20 May, causing more than 8000 deaths, 16 000 injuries, and large-scale devastation among the affected population. More than 25 hospitals and 1000 health facilities were completely or partly damaged. Re-establishment and continued provision of health care services in affected areas was a priority. (140) In order to ensure continuity of primary health care services until damaged health facilities were restored in earthquake-affected districts, WHO developed Medical Camp Kits (MCK) in collaboration with health partners. These kits were assembled at the camp as a temporary health facility. WHO immediately released these from the prepositioned emergency stockpiles along with several emergency medical supplies including Interagency Health Kits (IEHK). These kits support health services for up to 10 000 people for a period of three months. Also, 50 Medical Camp Kits (MCKs) and 80 medical tents to health facilities were among other emergency medical supplies that were provided to all 14 affected districts. (Fig 1) FIGURE 1: Medical Camp Kits reached on priority to countries in the South-East Asia Region Based on the experience gained in Nepal, with the planning, procurement, installation and maintenance of MCKs, WHO Nepal supported Member States in the SEA Region to strengthen the emergency preparedness and response readiness and emergency response through provision of MCKs. With horizontal collaboration, WHO Nepal assisted Bhutan, Bangladesh, Sri Lanka and Timor-Leste with the support of MCKs and hands-on onsite capacity building exercises to enable the WHO Country office staff, MoH and health partners to plan and establish MCKs during emergencies. Emergency Preparedness and Response Readiness during COVID-19 In the face of the unprecedented global COVID-19 pandemic which has seen critical shortages of essential medical supplies in addition to other logistical challenges, the criticality of maintaining and prepositioning essential medical supplies based on the forecasting model of needs and gaps was seen as a valuable support to Member Countries. The WHO Regional Office for SEA and the WHE programme were aligned with the Delhi Declaration. They ensured that stockpiling was a crucial mechanism for emergency preparedness and response readiness. Using SEARHEF to strengthen regional stockpiles of essential emergencies, medical supplies and equipment at the regional level before the COVID-19 pandemic, proved to be crucial for the immediate initial response to the pandemic. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 184 In normal times, WHO fulfils country requests by placing orders through long-term contracts with vendors who ship cargo via freight forwarders. The pandemic turned the process upside down. The unprecedented global situation created a whole new level of complexity and challenges with disruptions in global manufacturing, fractured supply chains, shortages in the face of soaring demand, increased market competition, trade restrictions and grounding of commercial flights. The COVID-19 Supply Chain System was introduced in April 2020 to scale up procurement and delivery of PPE, testing and diagnostic supplies, and biomedical equipment in a well-coordinated and organized manner. (141) WHO strived to improve the COVID Supply Portal for better delivery timelines and reduced shipment delays, better visibility with respect to end-to-end supply chain processes from requests to delivery etc. This WHO-led platform played a critical role in the fair allocation and distribution of quality-assured pre-qualified products in critical shortages to countries in a more coordinated and organized manner at lower rates. (Fig 2) FIGURE 2: WHO support to India during the 2nd wave of COVID-19 in 2021 Over 200 MT of medical supplies worth USD 10 million delivered to India within two weeks: 4041 oxygen concentrators 650 000 disposable sampling kits 124 high-performance and multipurpose tents 1.25 million respirator masks 400 000 RT PCR tests kits and consumables 424 medical beds The COVID-19 Supply Chain System was introduced in April 2020 to scale up procurement and delivery of PPE, testing and diagnostic supplies, and biomedical equipment in a well- coordinated and organized manner. © W H O /S EA RO 185Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Since the onset of the pandemic, WHO supported its SEA Member States with over 26 million essential COVID-19 supplies of PPE, diagnostic testing kits and biomedical equipment worth USD 52 million as of May 2021. This included over USD 10 million worth of support in the form of oxygen concentrators, tents and medical beds for COVID-19 treatment facilities, RT PCR testing kits and PPEs. Considering the lockdowns, exportation bans and limited shipping options, three strategic international warehousing locations for strategic regional stockpiling were identified for diversifying the risk of delay in response to ongoing and future emergencies and to provide timely support to Member countries with essential health commodities. These locations included the WHO Regional Office for SEA warehouse in New Delhi, India, WHO International Logistics Hub in Dubai, UAE and the UNHRD warehouse in Subang, Malaysia. These strategic regional stockpiling locations proved to be critical in ensuring timely support to Member countries in response to COVID 19 response and routine emergencies. Learnings from the pandemic to further streamline OSL The COVID-19 pandemic has shown the need to strengthen supply chain systems at all three levels of the Organization in order to build a more resilient supply chain system and to be better prepared for future global pandemics. Given how procurement and delivery of COVID-19 essential supplies has been managed, going forward it would be extremely important to plan for sufficient resources and initiate procurement well in advance. This will have to be based on the needs and gaps assessment of countries to ensure efficient utilization of limited donor funds. Long-term and sustainable assurance of funding will also ensure in strengthening OSL in order to build resilient supply chain systems at the national, regional and central levels for emergency preparedness and response readiness activities of the WHO. Since the onset of the pandemic, WHO supported its SEA Member States with over 26 million essential COVID-19 supplies of PPE, diagnostics testing kits and biomedical equipment worth USD 52 million as of May 2021. © W H O /S EA RO

14 C H A P T E R Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 188 © W H O /S EA RO 189Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region EFFECTIVE NETWORKING AND PARTNERSHIPS WHO relies on partners through networks, such as the Global Health Cluster, Standby Partners, EMTs and GOARN along with the support of Member States, regional associations such as ASEAN, SAARC, international partners, and local institutions to help communities prevent, prepare for, respond to, and recover from emergencies, disasters and crises. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 190 Recent years have shown extensive networking and collaborative mechanisms that have been set up to strengthen emergency preparedness, disease outbreaks and response in the Region. Although a lot more can be done to tap into the vast technical resources of Member States, seeing how some of these were set up, what specific functions they served and how these were adapted to country and emergency contexts, will guide future efforts in this direction. Regional Framework on Operational Partnerships for Emergency Response The Regional Framework on Operational Partnerships for Emergency Response (142) was released in early 2018 by the WHO Regional Office for SEA following a regional consultation in Bangkok, Thailand on 28–29 December 2017 in which 86 delegates from 54 agencies, including 11 Member States from the Region participated. © W H O 191Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region A regional guidance document was developed for the Member States and operational partners through learnings gathered from past experiences and lessons from the field of health emergencies. In many of these situations, coordinating emergency response and operations was tedious due to the presence of multiple numbers of humanitarian stakeholders with or without prior partnership agreements. Such situations often led to duplication of activities, a decline in quality and equitable distribution of emergency health services provisions. To have a timely, coordinated, effective and efficient emergency response, proper and organized utilization of resources scattered across multiple partners was needed as a means of emergency preparedness and operational readiness. Hence, the regional framework was developed to build, develop and expand operational partnerships for readiness, effective emergency response and early recovery, while bridging the gap with development planning through improved networking and coordination. The landscape of existing partners and stakeholders at the national and regional levels was elaborated, awareness raised among other stakeholders and further exploration for evolving partnerships with potential new stakeholders ongoing since then. Established mechanisms of partnerships for emergency preparedness and response include the Inter-Agency Standing Committee, the UN Office for Coordination of Humanitarian Affairs, Regional Office for Asia and Pacific- UN DRR, Global Health Cluster, EMTs, GOARN, multilateral and bilateral development partners (UNICEF, UNDP, World Food Programme, UN Women, IOM, World Bank, ADB and DRR- European Commission), WHO collaborating centres and other partners operating within SEA regional levels such as Asia-Pacific Emergency and Disaster Nursing Network, SEA Ministers of Education Organization- Tropical Medicine and Public Health Network (SEAMEO-TROPMED); international humanitarian NGOs (MSF, IFRC, Standby Partners) and private sector actors (Bill and Melinda Gates Foundation, Rockefeller Foundation, Reliance Health Foundation, Public Health Foundation of India, Federation of Indian Chambers of Commerce and Industries); and the regional economic and political groups such as ASEAN and SAARC. For operationalization of the regional framework, an implementation plan was developed in 2018, targeting collaboration and cooperation with WHO Country Offices, Member States and partners. The implementation plan considered the development of operational partnership mechanisms and agreements across all phases of the Health Emergencies and Disaster Risk Management cycle – right from preparedness, readiness and response to early recovery (build-back better). Essential components for successful building of operational partnerships • Contingency planning • Developing and expanding partnerships • Financial sustainability • Strengthening emergency response capacity • Information-sharing among health partners • Health partners mapping and coordination • Post-disaster needs assessment and partnership building across the continuum of the emergency management cycle across phases of readiness, emergency response and early recovery The Regional Framework draws heavily on the WHO ERF for M&E indicators and emergency response procedures following an incident management system. A regional guidance document was developed for the Member States and operational partners through learnings gathered from past experiences and lessons from the field of health emergencies. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 192 The Regional Office worked towards mobilizing with partners in strengthening contingency and readiness plans at each of the country levels. Partners and stakeholders working in any country in the Region were invited to contribute technical and financial resources in the development and implementation of the NAPHS. A special focus on strengthening national EMTs under the leadership and guidance of the Regional Working Group on EMTs consolidated the building and expansion of EMT initiatives in Bhutan, Indonesia, Sri Lanka and Thailand. The EMT of Thailand was verified and recognized under the WHO EMT Initiative as Type 1 internationally deployable while EMTs in Bhutan, Indonesia and Sri Lanka are in the pipeline for getting verified. Regional-level partnerships with GOARN were strengthened through regional- level meetings and establishing of GOARN, focusing on the SEA region and leveraging immediately deployable surge capacity. To date, over a dozen overseas experts have been deployed to support countries in different areas, be it clinical case management; implementation of Go.Data, an outbreak investigation tool for field data collection during public health emergencies; contact tracing, or supporting deep data analysis. (143) The Standby Partnership provides secondment of experts as surge capacity to humanitarian emergencies, was being managed at the WHO HQ. Efforts were made to decentralize this mechanism and evolve standby partnerships specific to the SEA region but did not yield any partnership agreement yet. The work on strengthening rapid response teams (RRT) through the implementation of a regional training module for ToTs is also in the offing through collaboration with the National Centre for Disease Control, India. Collaboration and partnerships during the COVID-19 pandemic While WHO’s leadership role for health emergencies within the United Nations system has been strengthened through the COVID-19 pandemic, both at the global and country-level, its unprecedented scale required everyone to come together for an efficient and effective response. A Global Partnership Forum was developed at the HQ level that was translated into action at the SEA regional level too. This platform was not only limited to operational partners but all stakeholders including governments. With the evolution of the pandemic, the platform was expanded to include coordination of response among all stakeholders, from planning and IARs to resource mobilization and supply chain management, as well as coordination of Regional COVID-19 vaccination drives. By mid-January 2020, with the rapid evaluation of the outbreak, the Regional Office of the UN Office for the Coordination of Humanitarian Affairs (OCHA) for the Asia Pacific Region Bangkok, Thailand established an ad-hoc Regional Working Group for COVID-19 to coordinate partners from the region. This Working Group included Regional counterparts of many partners from the Far East to the Western Pacific. With WHO being at the forefront in the technical response, the WHO Regional Office for SEA mobilized a senior Technical Officer from the WHO Country Office in Thailand as Liaison Officer to coordinate partners’ activities while closely collaborating with OCHA. Partners and stakeholders working in any country in the Region were invited to contribute technical and financial resources in the development and implementation of the NAPHS. 193Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region By February 2020, both the WHO Regional Office for SEA and the WHO Office for the Western Pacific Partnerships Focal Points added further technical support with a stronger element of coordination. The Working Group met (virtually) on a weekly basis for months into the response, supporting each other through multilateral and bilateral engagements. Several sub-working groups were established through this coordination mechanism for a specific response, which included, risk communication and community engagement, migration, logistics etc where WHO played a key technical role. Through intense engagement in these working groups and sub-groups, WHO continued to facilitate a coordinated response building synergy in the region. The Regional Office also collaborated with the UNDRR-Regional Office for Asia and the Pacific (RAOP) for mobilizing national disaster risk management authorities to integrate and provide their support in escalating response to COVID-19 through online training via webinars and supporting other areas of COVID-19 response. These included co-leading the Health Emergency Operations Centres (Maldives, Thailand, Nepal, Bangladesh), warehousing management of COVID-19 supplies and humanitarian relief (shelter, food, water and first aid care) for internal migrants who got stranded during severe restrictions on public movement in order to contain the transmission of SARS-CoV-2, and assisting in contact tracing and isolating of COVID-19 patients. Next, the Regional Office collaborated with ASEAN under the ASEAN-EU Strategic Partnerships funding for implementation of the ASEAN Strategic Framework for Public Health Emergencies (144) that was launched in November 2020, particularly in Member States of ASEAN (Indonesia, Myanmar and Thailand). This Strategic Framework has enhanced ASEAN’s preparedness, detection, response and resilience to public health emergencies with the goal of strengthening its cooperation in building regional health security. It will consider ASEAN mechanisms and tools under development, such as ASEAN S0Ps for coordination of EMTs, ASEAN Public Health Emergency Coordination System, Coordinating Centre for Animal Health and Zoonoses and the proposed ASEAN Centre for Public Health Emergencies and Emerging Diseases. The WHO Regional Office for SEA established a functional project office to implement this collaboration in countries that are also the Member States of ASEAN. Another evolving collaboration relates to rolling out an ongoing Regional Public Health Emergency Management Fellowship programme in India which will be supported by US CDC. This fellowship will encompass the capacity building of the staff of the PHEOCs to further strengthen the network of the PHEOC network. The criticality of PHEOCs for effective coordination has been highlighted in the global frameworks such as tools for monitoring and evaluation for IHR (2005), WHO Emergency Response Framework and Global Health Security Agenda, which the Member States endorsed and adopted. The need for closer collaboration and solidarity among operational partners is becoming greater amid the dynamics of the ongoing COVID-19 pandemic and concomitant emergencies resulting from other natural hazards. The WHO Regional Office for SEA is continuing its commitment and dedicated engagement with operational partners and stakeholders to ensure the Member States of the region are well supported in operational readiness and response to health emergencies. As of 2021, all 11 countries in the Region have established their Public Health Emergency Operation Centres (PHEOC) with minimum standards at least at the national level. Developing and maintaining state-of- the-art PHEOC networks in the region with diverse workforce of trained staff with different critical expertise; and tested plans and protocols are important to achieve expected emergency risk management outcomes envisaged in relevant global and regional frameworks and getting health systems to be operationally ready and resilient to manage shocks from public health emergencies and disasters. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 194 WHO CCs are global entities and the largest in-kind resource mobilization mechanism of WHO. Avian influenza, plague, scrub typhus, dengue, chikungunya, Zika virus, Nipah virus and leptospirosis have been emerging and re-emerging infectious diseases across the region. Unpredictable and unprecedented outbreaks of epidemic-prone diseases have an adverse impact not only on public health and the national economy but also on travel, trade and tourism. Many WHO CCs in SEA are members of GOARN and the Emerging Dangerous Pathogen Laboratory Network (EDLPN). Detection and reporting of zika virus in a European traveller who had a holiday trip to the Maldives through the IHR notification mechanism was a matter of serious concern for the tourism-dependent country. However, the WHO Regional Office for SEA coordinated with the Armed Forces Research Institute of Medical Sciences (AFRIMS) Bangkok, a WHO CC for emerging infectious diseases to provide agile support for outbreak investigation and appropriate control measures. It is important to note that AFRIMS Bangkok provided a referral service to confirm the chikungunya outbreak as well as outbreak investigation of re-emerging infectious disease namely scrub typhus in the Maldives. Similarly, AFRIMS extended referral service to confirm dengue outbreaks including serotyping to Nepal. The Regional Office also facilitated the availability of expertise and referral services from WHO CCs beyond the region; the University of Hong Kong and National Institute of Infectious Diseases (NIID) Tokyo to confirm human cases of avian influenza in Indonesia; Myanmar; Nepal, US CDC Atlanta to support Indonesia to develop plague surveillance Efficient and rational use of WHO Collaborating Centres in the South-East Asia Region system; Royal Tropical Institute (Amsterdam), WHO/FAO/ OIE CC for Reference and Research on leptospirosis to support surveillance, prevention and control in Indonesia and Sri Lanka. The Chulalongkorn University, Bangkok, WHO CC for viral zoonoses has been actively providing referral services and capacity building for the Nipah virus. This CC has been the National Reference Laboratory for confirmation of Ebola, MERS-CoV and SARS-CoV-2 in Thailand. This WHO CC carried out a molecular and serological investigation of SARS-CoV- 2-related coronavirus in humans and animals in Thailand from archived samples before the COVID-19 pandemic on the request and funding support of the R&D Blueprint SARS-CoV-2 programme and SARS-CoV-2 neutralizing antibodies have been detected in R. acuminatus bats from the Thai cave and Malayan pangolin (Manis javanica). R&D is important for emerging infectious diseases originating at the human-animal interface and there are WHO CCs, OIE Reference Laboratories and FAO Reference Centres for zoonoses in the Asia-Pacific region. WHO in collaboration with FAO, OIE and Hokkaido University in Japan organized an Asia-Pacific forum for Collaborating/ Reference Centers and Reference Laboratories working on EIDs and zoonoses in 2011 in Sapporo (Japan) in order to explore the possibility of mutual collaboration and to identify priority actions. It was the first time for many of them to know each other and the forum stressed the need to support capacity building for laboratory diagnosis, strengthening of biosafety and promoting an external quality assessment (EQA) system and technology transfer. Asia Pacific Risk Communication and Community Engagement (RCCE) Working Group RCCE plays a key role in an emergency. Community cooperation and support is essential for any public health response measure to succeed. However, in an emergency people are frightened and vulnerable. To win their trust requires listening to them, understanding them, respecting their way of life and providing them information in a manner that resonates with their realities. This involves multiple approaches and expertise, from socio-behavioural surveillance, rumour misinformation management and face-to-face engagement. In addition, working with media, including television, radio, community radio and social media. These require multiple levels of expertise and wide reach, and no agency can do this alone. With the COVID-19 pandemic, the UN, as part of its humanitarian response, established the Asia Pacific Risk Communication and Community Engagement Working Group bringing together all agencies working on RCCE in the Asia Pacific region. It was led by WHO, IFRC and UN-OCHA as co-chairs in 2020. In 2021, the co-chairs are WHO SEARO and WPRO, IFRC, and UNICEF ROSA and EAPRO. These require multiple levels of expertise and wide reach, and no agency can do this alone. 195Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Over 80 UN, international and national agencies work under the umbrella of this working group that is linked to the national RCCE Working Groups established in all countries of the Region and involving RCCE partners at the national level. Following the 4W’s (who, what, when and where) approach, it tracks what partners are doing where, and how they must coordinate amongst themselves. Regular monthly meetings are held to discuss issues of key importance, progress and achievements by any partner that can benefit others or be replicated. Among issues discussed were managing rumours and misinformation, socio- behavioural surveillance in countries, communication for vaccines, use of community radio and outcomes of perception studies through the COVID-19 pandemic. Trainings on conducting surveys were also held. The Working Group enabled different institutes to build on each other’s strengths to have a coordinated approach to risk communication. Global Outbreak Alert and Response Network (GOARN) in the Region The GOARN is a global technical partnership, established by WHO as a key mechanism to engage resources of technical agencies beyond the UN for rapid identification and confirmation of, and response to, PHIEC. The main objective of the network is to provide technical support to the WHO Member States experiencing a human health emergency due to various threats, including outbreaks of disease, lack of food safety, chemical toxins, zoonoses, and natural and manmade disasters. GOARN is an institution-based network and its partners include health and surveillance initiatives, regional technical networks, networks of laboratories, UN agencies (such as the United Nations Children’s Fund, United Nations High Commissioner for Refugees, United Nations Population Fund), the International Committee of the Red Cross and International Federation of Red Cross and Red Crescent Societies, international humanitarian NGOs (International Rescue Committee, MSF), national public health institutions and academia. The Working Group enabled different institutes to build on each other’s strengths to have a coordinated approach to risk communication. © W H O /B an gl ad es h Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 196 Whilst international deployments remain the main activity by which GOARN is globally recognized, the network has developed a suite of other initiatives to support outbreak response. They range from a well-established training programme targeted at enhancing soft skills and competencies of the multidisciplinary global workforce of outbreak respondents, to the development and roll out of contact-tracing tools (Go.Data), to efforts to improve outbreak response quality by promoting operational research. These efforts have been operationalized in the WHO SEA Region for the period 2011 to 2020. Deployments. In 20 years since its inception in 2000, GOARN has conducted over 160 operations and deployed over 3300 experts to assist more than 90 countries across the globe. In the 10-year period (2011–2020), as many as 2129 experts were deployed to 73 operations from 123 institutions. Besides deployments, GOARN provided support in technical discussions on following emergencies in the region for the nipah virus outbreak in India in 2018, Central Sulawesi Earthquake in 2018 and dengue outbreak in Cox’s Bazar. Assistance by GOARN partners in SEAR to global outbreak efforts has been rather meagre, despite significant capacities in several countries in the Region. Due to its protracted nature, assistance to Rohingya refugees in Cox’s Bazar merits special mention. During December 2017 to February 2019, a total of 43 experts were deployed to Bangladesh to assist in the humanitarian crisis. Technical experts were assigned to five main functions that included health expertise and operations, leadership, OSL, partner coordination and planning and information. The highest number (26) came from EURO region, followed by Western Pacific region (14) and Americas region (5). Six experts came from countries within the Eastern Mediterranean region, five from AFRO and one from SEA Region. Bangladesh, Nepal and Timor-Leste received maximum experts with epidemiology and case management being most demanded areas of expertise. © W H O /D PR K or ea Technical experts were assigned to five main functions that included health expertise and operations, leadership, OSL, partner coordination and planning and information. 197Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Partners engagement. The partnership started in 2000 with 67 institutions involved in global epidemic surveillance and response and has now grown to its 270-strong partnership. In the SEA Region, there are currently 22 GOARN partners. In the 10-year period there were three regional events involving GOARN partners and other relevant stakeholders to promote engagement with the network: i. an informal consultation in February 2012 in Bangkok, Thailand; ii. in 2012, Indonesia hosted the GOARN Regional Outbreak Response Course; and iii. an Operational Partnerships meeting was held in November 2017 that was attended by 40 organizations who developed a plan of action to re-engage partners in 2018. iv. Also, in 2017, two meetings were organized in Thailand and Indonesia to revitalize and increase the participation of the countries’ institutions and individual experts in the network. v. These were followed by two orientation workshops and the standard GOARN Tier 1.5 training conducted in Indonesia to introduce GOARN to potential partners in August 2019. An orientation workshop for partners in Thailand was held in December 2019 in addition to advocacy meetings with senior government officials in India and with WHO teams in Bangladesh and Sri Lanka. A critical mechanism for partners to engage with the strategic development of GOARN is through its Steering Committee. This is a representative body of 21 partner institutions that oversee the planning, implementation and evaluation of the Network activities and strategic goals. There has been regular attendance of SEARO representatives to frequent SCOM meetings, and the icddr,b Bangladesh which is the Region’s only representative at the Steering Committee. Capacity building. Experience has shown that when people with outstanding technical expertise are deployed to the field, they are not always equipped to apply these skills effectively in outbreak response settings. GOARN provides a comprehensive training programme that allows experts to work effectively in an A collaborative effort involving field epidemiologists and technical agencies from across the world culminated in the Epidemiologist R Handbook published in May 2021. The R Handbook was written by applied epidemiologists from around the world leveraging experience in local, national, academic and emergency settings. A collaborative effort involving many GOARN Partners, culminated in a team of authors and dozens of reviewers and supporting organizations including FETPs or TEPHINET, the EPIET Alumni Network (EAN), and MSF Operational Centre Amsterdam (OCA). This handbook is a true achievement The Epidemiologist R Handbook, a valuable resource for all involved and the epidemiology community as a whole. It begins with R fundamentals and proceeds through topics including data cleaning and management; descriptive and analytical approaches to linelist, survey, survival, contact tracing, time series, and geospatial data; creation of dashboards and automation of reports; how to generate figures such as epidemic curves, transmission chains, demographic pyramids, and phylogenetic trees; and epidemic modeLling. It also provides guidance for people looking to transition to R from other software such as SAS, Stata, SPSS, or Excel. This is a representative body of 21 partner institutions that oversee the planning, implementation and evaluation of the Network activities and strategic goals. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 198 international environment. The first tier of the programme introduces essentials for pre-deployment through a series of open access online self-directed eCourses. Online availability has increased the programme’s reach and opportunity for responders to access the multidisciplinary training repository. However, the SEA Region’s share in the uptake of these online resources remains low at just 6% of the global turnout. Language barriers, lack of reliable internet and suitable digital devices are cited as possible reasons. A Tier 3.0 leadership training was launched and started virtually in late 2020, with around 150 participants from 74 institutions across 54 countries taking part. About 18 participants from Myanmar, India, Bangladesh, Bhutan, Timor-Leste, Indonesia, Nepal and Thailand enrolled in the training. Other activities. GOARN in collaboration with WHO and partner organizations developed Go.Data, a software that allows conducting of outbreak investigations, including field data collection, contact tracing and visualization of disease chains of transmission. The joint project was an innovative use of digital technology for health operations that resulted from the cooperation of WHO and GOARN Partner institutions starting in 2015. In March 2019, WHO’s sub-office at Cox’s Bazar, Bangladesh, with support from GOARN, trained public health experts from the MoH, Institute of Epidemiology, Disease Control & Research (IEDCR), MSF, UN agencies, iNGOs and national NGOs in the use of Go.Data. Later in 2019, Go.Data was rolled out for contact tracing of the ongoing diphtheria outbreak in Cox’s Bazar. With COVID-19 in early 2020, countries faced the big challenge of rapidly tracing large contact chains. A number of countries in the Region benefited from technical support by HQ’s Go. Data team, especially once the WHO Regional Office for SEA had installed Go.Data in their servers. In the area of operational research, the large and protracted deployment effort to Bangladesh’s Cox’s Bazar Rohingya refugee camp allowed operationalization of a number of projects, some of which were compiled to populate a PLOS Medicine and PLOS One Special Edition publication on operational research. The work began in 2019 and in May 2021, two papers were accepted for publication with three more in advanced stages of review. Vision for the way forward GOARN in the SEA Region comprises fewer than 20 partners which is less than 10% of the global number of GOARN members. This is a limitation that prevents the Region from exerting its influence in the network’s decisions. It significantly limits the ability of the Region to contribute experts to international outbreak response efforts, within and beyond the Region, despite significant expertise and experience in outbreak response. This limitation became apparent during the COVID-19 pandemic where most requests for experts by the Member States had to be sourced from outside the Region. Efforts are now underway to increase the number of GOARN partners in SEA. Further, four new partners from the region have joined the network in 2020 and 2021. A sustainable solution in the coming months and years would be to develop national capacities and resilient outbreak response systems in countries. Delivering on these will require regular engagement with partners with a mixed portfolio of activities, ideally identified and led by them and catering for GOARN in the SEA Region comprises fewer than 20 partners, less than 10% of the global number of GOARN members. 199Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region a diverse skill-set of the network. To that end, operational funds and project management at the regional level will be required. Meanwhile, WHO relies on expert committees and technical advisors who do not necessarily have to be from within the Organization. The Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme (IOAC) recommended that the WHE Programme must make more robust use of WHO CCs, expert networks and public health institutes. These bodies can support WHO in generating technical recommendations, validated by them and thus supplement WHO’s capacity in a fast-moving crisis. Better use of WHO CCs and academic institutions in the region for support and research during the pandemic will be an advantage. Engagement with academia and teaching institutions, professional societies and civil societies at the country and regional level will further inform implementation and a wider replication of WHO-recommended best practices in public health emergencies. © W H O /C hr is tin e M cN ab

15 C H A P T E R Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 202 © W H O / Pl oy P hu tp he ng 203Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Setting up emergency response operations under the Incident Management System is a welcome initiative but not enough by itself. The WHE Programme supports areas affected by the disaster/emergency to help mount a coordinated response working with communities and Member States to track the evolution of an emergency that occurred due to natural hazards, disease outbreaks, technological catastrophes or civil conflicts. Scarce resources with the emergency response operation need to be utilized effectively and supported by evidence making the role of monitoring, evaluation and research extremely relevant. MONITORING, EVALUATION & RESEARCH: PROVIDING EVIDENCE FOR INTERVENTIONS AND DOCUMENTING LEARNINGS FROM PUBLIC HEALTH EMERGENCIES Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 204 T he WHO ERF (145) and the IHR Monitoring & Evaluation Framework (146) provide guidance on methodological processes and indicators for monitoring and evaluation (M&E) of emergency response operations on site and existing IHR core capacities for preparedness, operational readiness and response. The progress against meeting the objectives of an emergency response operation includes measures using the ERF Monitoring Tool which consists of emergency performance standards and key process indicators. The key process indicators are agreed upon on a case-by-case basis and reported monthly and are initially limited to no more than eight indicators. Examples of some of the indicators are as below: ĥ coverage and timeliness of the Early Warning Alert and Response System ĥ COVID-19 active caseload per day or week ĥ COVID-19 recovery rate among confirmed cases ĥ test positivity rate among tested samples for SARS-CoV-2 ĥ consultation rate for outpatient services ĥ bed occupancy rate (in ward and in ICUs) ĥ case fatality ratio for outbreak-prone diseases ĥ vaccination coverage; e.g., for measles, diphtheria/pertussis/tetanus (DPT3), first and second doses of COVID-19 vaccines ĥ percentage of births attended by a skilled birth attendant ĥ number and percentage of health facilities providing an essential package of health services. © W H O /P lo y Ph ut ph en g The key process indicators are agreed upon on a case-by- case basis and reported monthly and are initially be limited to no more than eight indicators. 205Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Regular monitoring of the emergency response operation through performance standards and process indicators help us in ascertaining if the emergency response interventions put in place are on track to meet the set objectives of reducing morbidity and mortality and facilitating nurturing of health and well- being in the affected communities. If at a certain point during the monitoring, some issues or reasons are found to be making the intervention ineffective, then the corrective actions can be implemented in collaboration with operational partners and other responsible areas. Encouraging the use of optional tools for evaluation The IHR M & E Framework provides and encourages the usage of optional tools such as SimEx, JEE and AARs that help in testing operational level capacities and capabilities in responding to emergencies. It also paves the way for further improving the Health EDRM capacities in a country. During the ongoing COVID-19 pandemic, the AAR tool was further adapted to evaluate response capacities and capabilities in the middle of an emergency response operation called IAR. The IAR tool helped Member States in knowing the strengths and weaknesses of ongoing response interventions across key pillars of the Country Strategic Emergency Preparedness and Response Plan for COVID-19. The IAR was successfully conducted in Bangladesh, Bhutan, Indonesia, Gujarat (India) and Thailand. The regional snapshot of the evaluation of IHR core capacities and emergency response operations is given in Table 1. State Party SPAR/ e-SPAR (Latest; in Year) JEE (Conducted in Year) AAR (Conducted in Year) IAR (COVID-19 Response) SimEx Bangladesh 2019 2016 2020 (14-20 December) Bhutan 2019 2017 2021 (25-26 February) SimEx on Bio-hazard specimens handling and Airport PoE Capacity (2019) at airport, COVID-19 (2020) DPRK 2019 Planned for 2019 but got delayed due to COVID-19 India 2019 Nipah Virus Outbreak (2018) 2020 (Gujarat) Indonesia 2019 2017 Pandemic Influenza (2018) Maldives 2019 2017 Influenza (H1N1) outbreak (2017) 2020 (11-14 August) Myanmar 2019 2017 Influenza (H1N1) outbreak (2017) Nepal 2019 Planned for May 2020 but got delayed due to COVID-19 Nepal Earthquake (2015), US-Bangla Air Crash 2018, Cholera 2017 Mass casualty management 2019, Influenza outbreak 2018 Sri Lanka 2019 2017 Dengue outbreak (2017) Thailand 2019 2017 2020 (20-22 July) Timor-Leste 2019 2018 Table1: Snapshot on evaluation of IHR core capacities and emergency response operations The IAR tool helped Member States in knowing the strengths and weaknesses of ongoing response interventions across key pillars of the Country Strategic Emergency Preparedness and Response Plan for COVID-19. Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region 206 Since different short-termed emergency events are reviewed as “After-Action Reviews”, the long duration emergencies of protracted grade e.g. the Rohingya Crisis in Cox’s Bazar, Bangladesh since August 2017’ may require annual operational review to evaluate the ongoing response operation. Firstly, an internal operational review was conducted in July 2018 involving all the four levels of the organization (Field Office, Cox’s Bazar, WCO Bangladesh, Regional Office and WHO HQ) that identified gaps and recommended strengthening response interventions. It was followed by an evaluation through external partners for identifying areas of improvement. External review of health service delivery for Rohingya refugees in Cox’s Bazar The surge of Rohingya refugees into Cox`s Bazar that began in August 2017, resulted in the engagement of international and national partners to meet their demand for health services. The health sector response shifted after a few months gradually from an initial emergency response to a more sustainable health service delivery model. Health facilities run by the many partners were not equally distributed throughout the camps and with variable technical capacity and quality of services. WHO, as health sector coordinator, therefore commissioned an External Review of Health Service Delivery in 2018 to inform health sector partners of current gaps, challenges and best practices. Despite major progress in accessibility and management of the large influx of refugees, the evaluation revealed the potential for misdiagnosis due to lack of adherence to technical protocols, often in connection to the increased number of patients visiting health facilities. There were concerns regarding technical competencies; doctors were often inexperienced and recently graduated. Some primary health care centres (PHC) lacked electricity and not all had laboratories. Also, where there was a laboratory, it was underutilized due to the absence or shortage of staff. The unplanned location of health posts and PHCs resulted in duplication of services and in incentivizing the “shopping behaviour” of refugees. Another key finding related to the lack of horizontal and vertical coordination as health staff was unaware of services being provided by other facilities around them and the lengthy process that awaited them for medical referrals. There were reports of issues regarding the quality of care in 24/7 facilities after hours. High occupancy and an overburdening of health facilities, especially for services related to ANC/PNC, neonatal care, child health, obstetrics and gynaecology, were recurring problems. Key recommendations from the review • Reassess geographic distribution of health posts as per minimum standards and based on needs; • Reduce duplication through rationalization/ optimization of the geographical distribution of health facilities; • Continuously update mapping of facilities and services provided per facility and strengthen coordination role of the national government and health sector; • Consider introduction of a health/service card to maintain health service records and streamline health service provision; • Provide induction workshops/training for all staff recruited for the health sector; • Develop simple, summarized and pictorial guidelines or algorithms for use by clinicians for most common diseases; and • Scale-up a triage system to improve the physical infrastructure of health facilities including the provision of electricity to all PHC centres. In the context of moving from an ad-hoc, emergency situation to a more coordinated effort in health service provision, it was suggested to improve coordination between the primary, secondary and tertiary levels of care, specifically in reducing delays during referrals. Designation of specialized centres for referrals and continuous monitoring of capacities needed to be prioritized. Given that medical staff in the camps was often young, capacity building and training to build skills in key protocols (IMCI, ANC/PNC, mhGAP), management and treatment of essential standards and most common diseases in the camps could greatly improve the quality of care. The findings of the external review were used to improve coordination, rationalization and effective targeting of the health sector’s response. The external review was carried out by KIT Royal Tropical Institute in the Netherlands. 207Towards a safer future Learnings from a decade of public health emergencies in the South-East Asia Region Independent Oversight and Advisory Committee for WHE Evaluation and systematic review of all emergency response operations that occurred in a year are facilitated by WHO HQ through an Independent Oversight and Advisory Committee or IOAC (147). The committee consists of eight members drawn from national governments, NGOs and United Nations Systems with extensive experience in several disciplines. The Committee advises WHO Director- General on issues within its mandate and reports its findings through the WHO Executive Board to the World Health Assembly. Based on an evaluation of the WHE programme done from May 2020 to April 2021 on COVID-19, a response was submitted to the 74th Session of the World Health Assembly in May 2021. (148) Research in emergencies Evidence is vital to well-informed decision-making in health emergency and disaster risk management. However, it is not an easy task, amidst competition and fast-changing priorities during an emergency or humanitarian crisis. Saving lives and serving people-in-crisis remains the foremost priority during the acute phase of an emergency response operation when public interests of safety, survival and well-being take precedence over research interests. (149) WHO R & D blueprint has been prepared as a global strategy and preparedness plan for facilitating rapid activation of R & D activities during epidemics. (150) It was used to accelerate innovations and research in diagnostics, vaccines and therapeutics for tackling SARS-CoV-2. Various innovative diagnostic kits and clinical drugs are designed and launched in the market to meet acute needs for improving and scaling up COVID-19 diagnosis in India. (151) The Regional Office contributed to the development of WHO Guidance on Research Methods and Disaster Risk Management and facilitating operational and implementation research relevant to the local context of an emergency at country levels. It ranged from adapting Medical Camp Kits to the local context of Nepal (2015) and Bhutan (2019) with tough geographical terrain to conduct of pulse surveys for assessing the impact of COVID-19 on EHS. (152, 153) The Regional Office supported countries to participate in solidarity clinical trials for COVID-19 treatments, (154) Unity studies for sero-epidemiological investigation protocols (155) and vaccine effectiveness studies in the Region. Moreover, the Regional Office is a core member of the WHO Thematic Platform for Health EDRM Research Network and actively participates in promoting collaboration among academia, government officials and other stakeholders to strengthen research, promote knowledge and evidence for managing health risks associated with all types of emergencies and disasters. (156) Saving lives and serving people- in-crisis remains the foremost priority during the acute phase of an emergency response operation when public interests of safety,survival and well-being take precedence over research interests. 1. Roots for resilience: a health emergency risk profile of the South-East Asia Region. World Health Organization Regional Office for South-East Asia. 2017. (https://apps.who.int/iris/bitstream/hand le/10665/258766/9789290226093- eng.pdf?sequence=5&isAllowed=y, accessed July 2021). 2. Leaving no one behind. World disasters report, 2018. 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