Valid Assessment and the Future of Health Security

Birth of the International Health Regulations

After the world failed to contain the 2003 SARS outbreak and it became a pandemic, the 2005 international health regulations (IHR) were born. The IHR included a mandate to report any cases of certain diseases (including SARS) to the World Health Organization (WHO) within 24 hours. Importantly the IHR requires all countries to be capable of preventing, detecting and responding to health emergencies.


Prevention and detection clearly failed at the outset for COVID-19. There is some evidence that a censured laboratory report identifying ‘SARS coronavirus’ emerged at Wuhan Central Hospital on 30 Dec 2019. Given the mandate to notify cases of SARS, and given the 2003 experience of a SARS pandemic, the WHO should have been able to declare a public health emergency of international concern (PHEIC) then and there. That did not happen. As it transpired a lack of Chinese transparency, politicisation, and reluctance to report the facts meant that the outbreak was not prevented, nor appropriately detected.

However, the IHR also mandates that countries ensure they are prepared to respond to global health threats. But once COVID-19 spread outside of China we saw how unprepared the world truly was.

This had been known for years. In 2012 only 42 of 194 States Parties to the IHR had self-reported compliance. This meant that 152 countries were not prepared to prevent, detect, or respond to significant health threats. Given the self-reported nature of the evidence, the reality may have been much worse. Two initiatives followed:

Invest and Measure

(1) the Global Health Security Agenda (GHSA) – a collaboration among many nations to enhance health security through investment and knowledge sharing, where notably the US invested nearly $1 billion in the health security of 31 developing nations.

(2) the Joint External Evaluations (JEE) with the WHO, whereby countries assessed their progress in conjunction with external teams, resulting in recommendations.

By 2018 only a minority of countries had yet undergone a JEE. Furthermore, it is apparent that many other factors contribute to health security beyond being prepared to prevent, detect and respond to outbreaks. For example, the quality of the health system and health workforce, the degree to which countries comply with international norms, and the risk environment. The world needed a universal and comprehensive measure of health security to identify gaps and target efforts.

The Global Health Security Index

The Global Health Security Index (GHSI) is such a tool and was used to measure health security capability of 195 countries across 140 items in 2019. The average global score was 40.2/100.

However, to be useful any measure of health security must be valid.

In a paper just published in BMJ Global Health, we report a validation analysis of the GHSI. Highlights are:

  1. The GHSI has face validity, being the culmination of a programme of work that began with a systematic search for factors that underpin health security.
  2. GSHI correlates strongly with measures of the JEE and so is useful for countries that have not yet undergone a JEE.
  3. GHSI correlates moderately with aggregate mortality from communicable diseases suggesting that increasing GHSI might improve disease outcomes.
  4. Countries that received US health security investments have higher GHSI (perhaps indicating the effectiveness of these investments).
  5. GHSI scores are typically higher for countries with past domestic cases of SARS (indicating that countries might learn from prior outbreaks).

Overall, we found that the GHSI is a somewhat valid measure of health security, that is perhaps best used by countries to identify gaps in health security that might warrant further analysis. This is exactly what the authors of the original GHSI report concluded in the same recent issue of BMJ Global Health: The value proposition of the GHSI.

Beyond the GHSI

However, the impact of COVID-19 makes clear that we need to address factors that the JEE and GHSI do not measure and perhaps cannot measure. Institutional knowledge, a sense of urgency, relationships established in living memory, cross-sectoral logistics and resilience, all these factors may be critical to responses, and difficult to measure.

Other overlooked factors may include: root cause analysis of laboratory accidents and near misses; gathering intelligence on biological threats; cyber-biosecurity practices; the capability to strictly manage borders and quarantine; the elimination of wet markets and wildlife trade; and the apparent negative impact of sanctions, federalism, the politicisation of media and misinformation and disinformation on social and mainstream media.

Enhancing health security needs to be one of the world’s foremost projects (in the vein of climate action). This is for a number of reasons:

  • The rising risk of accidental bioengineering disaster
  • The rising risk of powerful biological weapons
  • The rising risk of AI enhanced biological manipulations
  • The likelihood of future pandemics
  • The clear inadequacy of the present IHR to ensure protection
  • The obvious cost-effectiveness of preventing biological catastrophe

How Much Will it Cost?

The cost of bringing all countries up to a minimum level of health security is probably marginal in the context of COVID-19. We found some evidence that that the US investment of a mere $1 billion correlated with significantly higher GHSI scores on average across 31 countries (+6 points overall, +10 for detection & reporting). For context, $1b is only 1/2000th of the initial US Congress COVID-19 stimulus package. The WHO has estimated it would cost $100 billion to bring 67 developing countries up to IHR compliance. Given the stakes (trillions lost to COVID-19) this is a no brainer.

The Path Forward

More will need to be done, especially in light of COVID-19, including structural changes to the IHR, and the process by which WHO declares PHEICs. Developed countries should increase their overseas development assistance to the 0.7% of GDP recommended by the UN and target their own gaps in health security. Many critics have suggested paths forward, see the following links for examples:

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