Building Global Health Security Capacity: The Role for Implementation Science

Since the launch of the Global Health Security Agenda (GHSA) in 2014,^1-3 many countries around the world have accelerated efforts to achieve compliance with the World Health Organization's (WHO) International Health Regulations (IHR 2005) to build their capacities to detect, assess, and report public health events. ⁴ WHO approved a standardized Joint External Evaluation (JEE) tool in February 2016 that provides a framework for assessing a country's gaps and progress toward IHR 2005 implementation.^5,6 By October 2018, more than 86 countries in 6 regions had completed a JEE. ⁷ Based on JEE scores and recommended priority actions for improvement, multiple countries, in collaboration with technical partners such as the US Centers for Disease Control and Prevention (CDC), are actively working to build their capacities and strengthen core systems to prevent, detect, and respond to public health threats.

While notable progress has been achieved, many countries still fall short of IHR 2005 compliance. The need for more progress is further demonstrated by the 2018 Ebola outbreak in the Democratic Republic of the Congo and other recent infectious disease outbreaks around the world.^4,8,9 A scientifically grounded evidence base, derived from formal evaluation of work during IHR 2005 implementation, could not only help maintain momentum for continued progress and stakeholder support, but could also provide global guidance on how to improve ongoing implementation activities.

As the WHO Collaborating Center for Implementation of IHR 2005 Core Capacities since 2009, CDC assists WHO and its member states in building and sustaining national IHR core capacities. As a scientific public health agency, CDC pledges to “base all public health decisions on the highest quality scientific data that are derived openly and objectively.” ¹⁰

As governments throughout the world develop and implement their national action plans for health security to increase IHR 2005 capacities, it is necessary to increase the evidence base for IHR 2005 implementation to help inform plans, resource allocation priorities, and fiscal decisions for countries and donors. How does a government with limited resources discern which specific capacity-building approaches and interventions will enhance its ability to protect its population from threats that may not even be known today? What approaches are most effective and have the most impact in making progress on the IHR 2005 in specific technical areas such as laboratory, surveillance, workforce development, emergency response, and points of entry? What programmatic changes can be made to enhance the effectiveness and efficiency of current public health programs? What internal and external technical and fiscal contributions should a government prioritize to maximize impact? Applying approaches from the field of implementation science can help inform the answers to these questions.

Implementation science is an evolving field that focuses on identifying effective implementation approaches, on translating research findings into routine and common practices, and on evaluating factors that influence the efficient adoption and implementation of public health interventions in real-life settings.^11,12 Examples of implementation science areas of focus include acceptability, feasibility, costs, impact, and sustainability. ¹³ The goals of implementation science are to understand how newly developed and scientifically proven health interventions and policies are adopted, integrated, and sustained, as well as to provide information to policymakers and implementers on how these interventions can be strengthened. Over the past decade, the US government's global health programs and partners have applied implementation science to evaluate and assess disease control programs, service delivery approaches, and program impact.^14-18 The findings from these evaluations and studies helped major global programs employ more effective and efficient interventions.^19-21

The articles included in this supplement describe lessons learned and present evidence from evaluations of efforts to build global health security capacity. By focusing current global health security programmatic and scientific work on implementation science, more useful evidence is generated that countries, stakeholders, collaborators, and donors need to more rapidly and efficiently build the sustainable health security capacities needed to meet the goals of IHR 2005.^13,22 Development of a strategic scientific framework for global health security is necessary to provide the global public health community with an approach to studying the implementation of programs aimed at building capacity to prevent, detect, and respond to these public health threats. This framework should incorporate implementation science to assist in prioritizing investments by identifying the most effective interventions to strengthen global health security. Table 1 provides some examples of CDC's areas of interest for global health security implementation science through determining most effective interventions and measuring impact. The framework should also include a focus on basic epidemiologic research and surveillance to understand the causes of disease, as well as to characterize the burden and risk factors for these diseases; this is necessary to inform public health decision makers on which interventions should be developed, implemented, and evaluated to accelerate and optimize global health security.

Table 1.

Examples of CDC's Areas of Interest for Global Health Security Implementation Science

Determine the Most Effective Implementation Approaches

Assess best practices for program implementation. Evaluate current practices to identify feasibility, acceptability, and effectiveness of the intervention. Determine optimal number of trained field epidemiologists and surveillance officers per population or per subnational jurisdictional unit to appropriately detect, respond to, and control public health threats. Examine the impact, costs, and cost-effectiveness of different models for the development of an effective and efficient public health workforce. Examine health systems to quantify the impact of having several vertical public health surveillance programs (eg, human immunodeficiency virus, tuberculosis, Expanded Program on Immunization, malaria, and influenza) with an integrated surveillance system. Compare the impact, costs, and cost-effectiveness of different models of laboratory specimen transport systems. Assess impact, cost, and cost-effectiveness of rapid diagnostic tests in field settings. Compare the impact, costs, and cost-effectiveness of different interventions, including emergency management approaches, in humanitarian and other emergencies.

Measure Impact

Measure the differences in outbreak response capacity before and after public health investments in terms of days to detection, days to response, days to outbreak control, etc. Measure the impact of enhancements in public health surveillance, laboratory systems, and enhanced emergency response in terms of number of outbreaks controlled, cases averted, time lags from specimen detection to collection, etc. Measure the impact of an increase in trained public health workforce in terms of number of outbreaks controlled, cases averted, time lags from specimen detection to collection, etc. Quantify the impact of key health interventions, such as childhood immunization, nutritional supplementation, etc. Measure how programs for the prevention and control of noncommunicable diseases reduce the burden of illness .

Over the past 4 years, the world has seen significant investments in programs aimed at building surveillance, laboratory systems, and response capacity in regions hit hardest by public health threats.^23-25 Now is a good time to use implementation science to learn as much as possible from these investments and share the evidence and lessons learned with all global health security partners to guide future efforts.

Partners from around the world working to strengthen global health security may benefit from incorporating implementation science into their capacity-building efforts, as it is critically needed to guide future investments for the implementation of IHR 2005. This can lead to an accelerated progress toward a world safe and secure from global health threats.