The Importance of Establishing a National Health Security Preparedness Index

Abstract

Natural disasters, infectious disease epidemics, terrorism, and major events like the nuclear incident at Fukushima all pose major potential challenges to public health and security. Events such as the anthrax letters of 2001, Hurricanes Katrina, Irene, and Sandy, severe acute respiratory syndrome (SARS) and West Nile virus outbreaks, and the 2009 H1N1 influenza pandemic have demonstrated that public health, emergency management, and national security efforts are interconnected. These and other events have increased the national resolve and the resources committed to improving the national health security infrastructure. However, as fiscal pressures force federal, state, and local governments to examine spending, there is a growing need to demonstrate both what the investment in public health preparedness has bought and where gaps remain in our nation's health security. To address these needs, the Association of State and Territorial Health Officials (ASTHO), through a cooperative agreement with the Centers for Disease Control and Prevention (CDC) Office of Public Health Preparedness and Response (PHPR), is creating an annual measure of health security and preparedness at the national and state levels: the National Health Security Preparedness Index (NHSPI).

“In the past year, I have been struck by how important measurement is to improving the human condition. You can achieve incredible progress if you set a clear goal and find a measure that will drive progress toward that goal. …” —Bill Gates ¹

“What gets measured gets done.” —Peter Drucker ²

It is well accepted that a nation's public health and national security are inextricably linked. Natural disasters, infectious disease epidemics, terrorism, and major events like the nuclear incident at Fukushima all pose major potential challenges to public health and security. Events such as the anthrax letters of 2001, Hurricanes Katrina, Irene, and Sandy, severe acute respiratory syndrome (SARS) and West Nile virus outbreaks, and the 2009 H1N1 influenza pandemic have demonstrated that public health, emergency management, and national security efforts are interconnected.

These and other events have increased the national resolve and the resources committed to improving the national health security infrastructure. There has been a substantial amount of work undertaken by the whole preparedness and response community to prepare for these threats. With this resource commitment and work, there is increased recognition of the importance of measuring the resulting progress, identifying interventions moving forward that are most efficient and efficacious, and providing the public with evidence that the outcomes have an impact and are worth the investment. This is especially important in light of resource constraints associated with current domestic and global economic conditions.

To address these needs, the Association of State and Territorial Health Officials (ASTHO), in partnership with the Centers for Disease Control and Prevention (CDC) Office of Public Health Preparedness and Response (PHPR), is creating an annual index that will help measure health security and preparedness at the national and state levels: the National Health Security Preparedness Index (NHSPI).

Progress in Preparedness

Public health preparedness and response has improved considerably since the terrorist attacks on September 11, 2001.^3,4 The Public Health Security and Bioterrorism Preparedness Act of 2002 authorized increased federal funding and focus areas for public health, including improving public health capacity, improving health worker preparedness for identifying and/or treating bioterrorism-associated diseases, accelerating medical countermeasure development, and improving tracking and regulating of dangerous pathogens. ⁵ As a result, CDC established the Public Health Emergency Preparedness (PHEP) Cooperative Agreement Program. ⁶ This program supports more than 5,000 frontline public health workers in states, territories, and localities with funding, guidance, and scientific and programmatic expertise as they strengthen their abilities to respond to all types of public health incidents, build more resilient communities, and respond to everyday public health threats and emergencies.

Recognizing that public health is a major component of national security, the Pandemic and All-Hazards Preparedness Act (PAHPA) of 2006 expanded the focus to growing areas of concern such as emerging infectious diseases and natural disasters, in addition to intentional threats from biological agents and other weapons of mass destruction. ⁷ The US Department of Health and Human Services (HHS) released its National Health Security Strategy in December 2009, ⁸ and in September 2011, CDC released its National Strategic Plan for Public Health Preparedness and Response, ⁹ outlining goals for improving public health security. The White House released Presidential Policy Directive 8 (PPD-8) in March 2011, which called for a National Preparedness Goal with 5 core mission areas: prevention, protection, mitigation, response, and recovery. ¹⁰ PPD-8 also called for a National Preparedness System that serves as a basis for national, state, and local partnerships.

As the complexity, breadth, and novelty of threats and hazards evolve, the need to measure the impact of planning and interventions becomes more necessary, yet also more challenging. The challenge in measuring health security preparedness is that catastrophic events thankfully occur infrequently. Often, in order to measure outcomes, we rely on daily, routine threats and our responses to them. As we build the NHSPI, we will need to balance measuring national health security through “direct” observation of the response to catastrophic events with measuring “indirectly” both when the system responds to routine threats and in how basic, existing public health infrastructure contributes to the overall response capability. An “index” approach is routinely accepted as a way to measure change that cannot be observed directly.

Index numbers are commonly used to assess components of the complex national economy, which itself cannot be directly quantified. For example, the Consumer Price Index (CPI) is a relative-reference index that measures inflation (another entity that cannot be directly measured) by collecting the current prices of more than 60,000 consumer goods across a broad spectrum of industries and comparing them to a price baseline, defined as what those items cost in 1984. ¹¹ CPI is not a perfect and absolute measure of inflation; however, it is an effective measure of monthly changes in prices that indicate the degree of inflation (or deflation). CPI components also provide insight into inflation drivers.

Many other economic-related examples exist, including widely used indices for stock and bond markets, market share and industry competition, housing affordability, and consumer confidence. Index numbers do not need to be confined to economic measures; ¹² examples related to public health include the use of index numbers for hazard metrics. ¹³ Bhagat et al described the feasibility of designing an index for sustainability, a topic whose definition may vary depending on whether it is being used in the context of business, policymaking, or social discussions. ¹⁴ A well-designed index can provide a better understanding of complex interdependencies to guide professional and public activities. Such a measure, when it exists, may also provide insight and guidance for the nation's health security preparedness improvement efforts.

The National Health Security Preparedness Index (NHSPI)

Health security preparedness, like inflation, unemployment, and economic productivity, must be derived from individual values of the underlying elements that define it and are amenable to direct measurement. The NHSPI will represent a single summary measure for each state that communicates the current level of health security preparedness in a consistent, standardized way. For those interested in a particular state's score, this NHSPI summary measure will also be broken down into subcomponents so a user could look at states across a certain domain or subdomain. The NHSPI's mission will be to present an accurate portrayal of public health preparedness that provides relevant, actionable information to drive decision making and continuous improvement of the nation's health security.

The NHSPI will give objective, evidence-based measures to policymakers and practitioners. Policymakers will be able to use the NHSPI to assess the progress in preparedness to date and to guide inquiry needed to inform decisions about investments. Practitioners will be able to use the NHSPI to help understand the interdependencies of the health security preparedness system and help benchmark and facilitate quality improvement at the state and local levels.

The NHSPI will be a composite index reflecting a range of elements that have an impact on health security preparedness. It will:

• Focus initially on public health and healthcare systems, but it is envisioned to include other elements over time;

• Use already established metrics, creating new data reports only where gaps exist;

• Align with and support, but not be limited by, existing national frameworks (PPD-8, the National Preparedness Goal, National Health Security Strategy, etc.);

• Be developed using recognized processes that underlie other composite indicators;

• Use national quality forum criteria for measurement, wherever possible; and

• Undergo continuous quality improvement (CQI).

To lead the development of the NHSPI, ASTHO has assembled more than 75 experts from across key stakeholder categories including public health, emergency management, private sector, nonprofits, government, and academia. These individuals bring practical, “boots-on-the-ground” experience and technical knowledge across public health, mathematics, modeling, communications, and governance.

The NHSPI development process has built in and anticipates even further expanding opportunities for broad involvement of the preparedness and response workforce and other community stakeholders to provide both direction and feedback. Development of the NHSPI will be a multiyear process, with the focus of the first year being on public health preparedness and healthcare system preparedness. Future versions of the NHSPI may potentially add other elements and drivers of health security (eg, emergency management, emergency medical services, legal preparedness, industry, preevent community health status).

An initial draft model of the NHSPI will be complete by the end of March 2013. This developmental draft will be distributed to state health officials, preparedness directors, and related association partners for the purpose of gaining feedback and strengthening the index. After this early development phase is complete, the NHSPI will be released more widely with the goal of generating much broader stakeholder engagement. As with other major indices, the NHSPI will evolve through an ongoing process of rollout, testing, application, and revision.

Conclusion

The NHSPI is a tool being developed to improve the science and practice of preparedness through the application of standardized national measures. It is intended to help the preparedness and response community better identify best practices, demonstrate the impact of their work, and ensure that funding and resource needs are supported by data. It will allow organizations to benchmark quality improvement initiatives and provide policymakers and planners with information to make better-informed policy decisions. For more information, please visit www.nhspi.org.