Analysis BMJ Glob Health: first published as 10.1136/bmjgh-2020-003648 on 8 October 2020. Downloaded from The value proposition of the Global Health Security Index 1 1 1 1 Sanjana J Ravi , Kelsey Lane Warmbrod, Lucia Mullen, Diane Meyer, Elizabeth Cameron,2 Jessica Bell,2 Priya Bapat,3 Michael Paterra,3 Catherine Machalaba,4 Indira Nath,5 Lawrence O Gostin,6 Wilmot James,7 Dylan George,8 Simo Nikkari,9 Ernesto Gozzer,10 Oyewale Tomori,11,12 Issa Makumbi,13 Jennifer B Nuzzo1 To cite: Ravi SJ, ABSTRACT Summary box Warmbrod KL, Mullen L, Infectious disease outbreaks pose major threats to human et al. The value proposition health and security. Countries with robust capacities ► Infectious disease outbreaks pose major threats to of the Global Health Security for preventing, detecting and responding to outbreaks Index. BMJ Global Health human health and economies. can avert many of the social, political, economic and 2020;5:e003648. doi:10.1136/ ► The Global Health Security Index (GHS Index) can health system costs of such crises. The Global Health bmjgh-2020-003648 help decision makers identify weaknesses in sys- Security Index (GHS Index)—the first comprehensive tems for preventing, detecting and responding to assessment and benchmarking of health security and Handling editor Seye Abimbola outbreaks, while also considering relevant social, related capabilities across 195 countries—recently found political and environmental risk factors. Received 6 August 2020 that no country is sufficiently prepared for epidemics ► Using publicly available information, the GHS Index or pandemics. The GHS Index can help health security Revised 10 September 2020 documents where health security capacities are Accepted 11 September 2020 stakeholders identify areas of weakness, as well as strong and where they are weak. opportunities to collaborate across sectors, collectively ► GHS Index scores and ranks are entry points into strengthen health systems and achieve shared public deeper analyses of health system capacities and health goals. Some scholars have recently offered performance. constructive critiques of the GHS Index’s approach to ► GHS Index scores cannot and do not predict how scoring and ranking countries; its weighting of select countries respond to outbreaks, nor how many cas- indicators; its emphasis on transparency; its focus on es or deaths a country will report during an outbreak. biosecurity and biosafety capacities; and divergence ► Future iterations of the GHS Index will incorporate between select country scores and corresponding COVID- lessons learnt from the ongoing COVID-19 pandemic. 19- associated caseloads, morbidity, and mortality. Here, http://gh.bmj.com/ we (1) describe the practical value of the GHS Index; (2) present potential use cases to help policymakers and practitioners maximise the utility of the tool; (3) discuss the the course of the GHS Index’s development importance of scoring and ranking; (4) describe the robust and participated in their personal capacities methodology underpinning country scores and ranks; or in their capacities as representatives of (5) highlight the GHS Index’s emphasis on transparency advising organizations.” The inaugural itera- on September 23, 2021 by guest. Protected copyright. and (6) articulate caveats for users wishing to use GHS tion of the GHS Index was generously funded Index data in health security research, policymaking and by the Open Philanthropy Project, the Bill & practice. Melinda Gates Foundation and the Robertson Foundation. The GHS Index is the first comprehensive assessment of health security and related capa- INTRODUCTION bilities across the 195 countries that make up The Global Health Security Index (GHS the States Parties to the International Health © Author(s) (or their Index) is a project by the Nuclear Threat Regulations (IHR (2005)). It promotes employer(s)) 2020. Re- use Initiative and the Johns Hopkins University meaningful multisectoral engagement to permitted under CC BY-NC. No commercial re- use. See rights Center for Health Security, with methodo- complement existing processes for national and permissions. Published by logical, research, and analytical support from health security needs assessment, prioritisa- BMJ. The Economist Intelligence Unit (EIU). An tion, planning and financing, and is a tool For numbered affiliations see International Panel of Experts, convened for measuring country capacities to prevent, end of article. by the project team, provided guidance and detect and respond to naturally occurring, Correspondence to feedback on the development of the GHS accidental and deliberate infectious disease Dr Sanjana J Ravi; Index framework. Members of the Interna- threats. Building on the World Health Orga- sanjana@ jhu. edu tional Panel of Experts provided advice over nization’s (WHO) Joint External Evaluation Ravi SJ, et al. BMJ Global Health 2020;5:e003648. doi:10.1136/bmjgh-2020-003648 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2020-003648 on 8 October 2020. Downloaded from (JEE) tool, the GHS Index also assesses health system national, regional and global trends in health security- preparedness for high- consequence outbreaks, as well as strengthening efforts over time, identify when countries socioeconomic and political risk factors that modulate deprioritise investments and capacities and include new vulnerability to epidemic threats. The inaugural GHS measures of pandemic preparedness informed by global Index, released in 2019, found that no country is suffi- experiences with COVID-19. Globally and nationally, ciently prepared for epidemics or pandemics.1 the GHS Index also identifies existing vulnerabilities in COVID-19 and other recent outbreaks—such as H1N1 preparedness for biological threats. Systematically cata- pandemic influenza, Ebola, Nipah and Zika, among loguing and monitoring these weaknesses could help others—underscore the importance of measuring and inform budget allocations and spending decisions, and monitoring country progress towards building robust aid policymakers in setting priorities for health security- capacities for preventing, detecting and responding to strengthening and health systems- strengthening efforts. known, emerging and re-emerging infectious disease Finally, the GHS Index is valuable in its framing of threats.2 These outbreaks have also underscored chal- global health security as a multisectoral social project. lenges in measuring global health security capacities. Effective outbreak prevention, for example, depends in Some analyses, for example, have recently highlighted part on addressing root causes of disease emergence, such discrepancies observed in countries like the USA and the as those captured in GHS Index indicators examining UK, which received high GHS Index and JEE Scores, yet land use changes, veterinary workforces and agricultural struggle to suppress cases of COVID-19.3 4 practices. This multisectoral lens—which incorporates Here, we (1) describe the practical value of the GHS measures of country fragility and other political, economic Index; (2) present potential use cases to help policy- and environmental vulnerabilities—creates a tangible makers and practitioners maximise the utility of the starting point for One Health coordination platforms or tool; (3) discuss the importance of scoring and ranking; national disaster management committees to work across (4) describe the robust methodology underpinning sectors, engage non- traditional partners and formulate country scores and ranks; (5) highlight the GHS Index’s multisectoral solutions to complex health challenges. emphasis on transparency and (6) articulate caveats for Though processes like JEEs and NAPHS development users wishing to use GHS Index data in health security are intended to be multisectoral, it is the health sector research, policymaking and practice. that most often functions as the entry point for other stakeholders and sectors that may not have explicit mandates to strengthen health security.6 The GHS Index THE PRACTICAL VALUE OF THE GHS INDEX thus recognises—and measures—the benefits of whole- The GHS Index could serve as a powerful tool for meas- of- society approaches to health security that transcend uring and motivating sustainable financing at national, any one sector. regional and global levels, and its findings could help catalyse political will to fill gaps in health security capacity. http://gh.bmj.com/ The GHS Index also measures indicators directly related to epidemic and pandemic preparedness alongside THE VALUE OF SCORING AND RANKING indicators of broader strengths needed to reinforce Scoring is an intuitive method of summarising complex health systems, such as political, security and socioeco- health system capacities across diverse contexts, moni- nomic factors that could shape country risk landscapes toring longitudinal and cross-sectional trends and advo- cating for needed policy change. Scoring is also used and capacities to prevent, detect and rapidly respond to on September 23, 2021 by guest. Protected copyright. outbreaks. Additionally, it complements ongoing efforts widely across many areas of global health, economic, to build accountability for national preparedness, such as policy and development research, as well as in established 7–10 the Global Preparedness Monitoring Board, the Global health security evaluation tools like the JEE. Health Security Agenda (GHSA) and the World Bank In general, scoring is an effective method for measuring, Health Emergency Preparedness