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Emergency Preparedness and Public Health Systems

Lessons for Developing Countries
  • Margaret E. Kruk
    Correspondence
    Address correspondence and reprint requests to: Margaret E. Kruk, MD, MPH, University of Michigan School of Public Health, Department of Health Management and Policy, 109 Observatory Road, SPH II M3166, Ann Arbor MI 48109.
    Affiliations
    University of Michigan School of Public Health, Department of Health Management and Policy, Ann Arbor, Michigan, and the Averting Maternal Death and Disability Program, Columbia University Mailman School of Public Health, New York, New York
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      Abstract

      Low- and middle-income countries, where emerging diseases often make their debut, are also likely to bear the harshest consequences of a potential influenza pandemic. Yet public health systems in developing countries are underfunded, understaffed, and in many cases struggling to deal with the existing burden of disease. As a result, developed countries are beginning to expand assistance for emergency preparedness to the developing world. Given developing countries' weak infrastructure and many competing public health priorities, it is not clear how to best direct these resources. Evidence from the U.S. and other developed countries suggests that some investments in bioterror and pandemic emergency preparedness, although initially implemented as vertical programs, have the potential to strengthen the general public health infrastructure. This experience may hold some lessons for how global funds for emergency preparedness could be invested in developing countries to support struggling public health systems in responding to current health priorities as well as potential future public health threats.

      Introduction

      Improving the capacity of developing countries to respond to emerging diseases and especially influenza pandemics is essential to reduce both transmission around the globe and the human toll of outbreaks in the developing world. Investing in this capacity in developing countries is thus increasingly seen as a shared concern within the global community. As a result multilateral and bilateral donors committed a total of US$582 million in loans and grants to buttress the response capacity of developing and middle-income countries.
      World Bank
      Avian and human influenza: update on financing needs and framework.
      While there is broad agreement on the need for additional funding, there is less clarity on how the funds should be spent. Although the developed world has invested its bioterror- and pandemic-preparedness dollars and euros into building highly specialized emergency-response capacity, it is not clear whether this could or should be replicated in the developing world, where public health infrastructure is weak due to years of under-investment and where there are urgent, competing public health priorities that by necessity take center stage.
      • Calain P.
      From the field side of the binoculars: a different view on global public health surveillance.
      This article examines the value of a multiple-use approach to emergency preparedness in the developing world—one that aims to build capacity for both emergency preparedness and current core public health activities. Such an approach could offer developing countries an opportunity to strengthen their public health system platforms, allowing them to respond to multiple priority diseases rather than creating specialized programs that will likely be difficult to sustain in the longer term. First, it reviews evidence from developed countries on the impacts of emergency preparedness for bioterrorism and pandemic influenza—which require similar public health system responses—on public health departments and the overall public health system, focusing on investments proven to have substantial collateral impacts on other public health activities. It then explores how similar multiple-use investments could be made in the developing world.

      Background

      There is growing concern that the world is facing an influenza pandemic caused by a mutated avian virus. In 2003/2004, an outbreak of the H5N1 subtype of influenza A killed or caused the destruction of 150 million birds in Asia—the largest such outbreak in history. Two hundred and five people were infected with an overall case fatality rate of 56%.
      • Chen J.M.
      • Chen J.W.
      • Dai J.J.
      • Sun Y.X.
      A survey of human cases of H5N1 avian influenza reported by the WHO before June 2006 for infection control.
      Epidemiology of WHO-confirmed human cases of avian influenza A(H5N1) infection.
      If H5N1 or a similar virus improves the efficiency of its human-to-human transmission, such an outbreak could precipitate a major global pandemic.
      World Bank
      Avian and human influenza: update on financing needs and framework.
      Globally, other emerging diseases, such as Ebola, Marburg; drug-resistant tuberculosis (TB); and others are also on the rise.
      CDC
      Emerging infectious diseases.
      Jungles and other ecosystems in low- and middle-income countries have frequently been the source of emerging diseases. The Ebola, Marburg and Lassa hemorrhagic fever viruses, as well as the virus responsible for Rift Valley Fever, are native to Africa. H5N1 influenza spread from migratory birds in Asia to birds in Africa and Europe in 1996—a path that could be followed by a more lethal human form of the virus.
      • Juckett G.
      Avian influenza: preparing for a pandemic.
      At the same time, the public health infrastructures in developing countries that must contain these new threats are weak and stretched thin with the current disease burden. Indeed, health systems in the lowest-income countries suffer from insufficient health system funding, large shortages of health workers, and dilapidated infrastructure, particularly in rural areas.
      WHO
      Macroeconomics and health: investing in health for economic development; report of the Commission on Macroeconomics and Health.
      Joint Learning Initiative
      Human resources for health: overcoming the crisis.
      In 2003, for example, 34 of the 46 countries in the WHO African region spent less than US$34 per capita on health, the minimum amount recommended by the Commission on Macroeconomics and Health, with 29 of the countries spending US$20 or less.
      WHO
      Macroeconomics and health: investing in health for economic development; report of the Commission on Macroeconomics and Health.
      WHO
      World health statistics 2006.
      As a result, many countries struggle to provide routine immunization and healthcare services for common disorders, much less offer routine surveillance of influenza-type illness.
      Recent experience with emerging diseases suggests that weak outbreak notification and containment may lead to high mortality and morbidity. In the 2000–2001 Ebola outbreaks in Uganda, a lack of gloves, masks, and gowns, as well as inconsistent sterilization in hospitals, increased the rates of transmission of the disease to healthcare workers and other patients.
      • Lamunu M.
      • Lutwama J.J.
      • Kamugisha J.
      • et al.
      Containing a haemorrhagic fever epidemic: the Ebola experience in Uganda (October 2000–January 2001).
      People who become infected often have higher fatality rates because supportive or curative treatment is not routinely available, and a lack of information about disease transmission may delay the seeking of treatment.
      CDC
      Emerging infectious diseases.
      The link between poverty and high epidemic mortality is confirmed by historic experience. Vital registry data from the influenza epidemic of 1918, which likewise may have originated in birds, showed a 30-fold difference in mortality rates between some of the most- and least-developed regions of the world; this is thought to be due in large part to the effects of poverty, including the lack of supportive care, as well as poor nutrition and high levels of comorbidity.
      • Murray C.J.L.
      • Lopez A.D.
      • Chin B.
      • Feehan D.
      • Hill K.H.
      Estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918–20 pandemic: a quantitative analysis.
      • Taubenberger J.K.
      • Reid A.H.
      • Lourens R.M.
      • Wang R.
      • Jin G.
      • Fanning T.G.
      Characterization of the 1918 influenza virus polymerase genes.
      While experts note that even in the U.S. a major influenza epidemic would likely overwhelm the public health capacity, epidemiologic modeling suggests that if a global influenza pandemic similar to that of 1918 were to have happened in 2004, 96% of the deaths globally would have been in developing countries, with 59% in sub-Saharan Africa and South Asia, two of the world's poorest regions.
      • Murray C.J.L.
      • Lopez A.D.
      • Chin B.
      • Feehan D.
      • Hill K.H.
      Estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918–20 pandemic: a quantitative analysis.
      • Duley M.G.
      The next pandemic: anticipating an overwhelmed health care system.
      • Levin P.J.
      • Gebbie E.N.
      • Qureshi K.
      Can the health-care system meet the challenge of pandemic flu? Planning, ethical, and workforce considerations.
      The mortality rate would be 1.6% in sub-Saharan Africa and South Asia versus 0.2% in the wealthy countries belonging to the Organization for Economic Co-operation and Development (OECD).
      • Murray C.J.L.
      • Lopez A.D.
      • Chin B.
      • Feehan D.
      • Hill K.H.
      Estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918–20 pandemic: a quantitative analysis.

      Preparedness and Public Health Systems in the Developed World

      The 2001 terrorist attacks on the World Trade Center and the subsequent release of anthrax shocked the U.S. into taking stock of the emergency response capacity of its public health systems. Significant additional funding to strengthen this capacity followed. In the U.S., the biodefense preparedness budget increased from $294 million in 2001 to $3 billion in the next year and to $5.2 billion in 2004. Of the funds committed since 2001, $3.6 billion was spent on state, local, and hospital preparedness, representing a substantial infusion of new money into public health systems that had seen little new funding in the preceding decade.
      USDHHS
      HHS accomplishment in biodefense preparedness.
      At the same time, the European Union (EU) established the Health Security Committee to develop a health information system, EU-wide surveillance, a database of the medicines stock, a facility to disseminate medicines and specialists, and health-specific protocols for a coordinated EU response to an attack.
      • Gouvras G.
      The far-reaching impact of bioterrorism What the European Union is doing regarding deliberate releases of biological/chemical agents based on the events in the U.S..
      By 2006 a growing concern about the possibility of pandemic influenza of avian origin in the U.S. led to an infusion of another $3.8 billion into preparedness activities.
      The White House
      Fact sheet: advancing the nation's preparedness for pandemic influenza.
      The bulk of preparedness budgets in the U.S. was allocated to a range of related health activities intended to respond to acts of bioterror, emerging infectious diseases, and later pandemic influenza. Bioterror and pandemic preparedness investments included the upgrading of disease surveillance, hospital capacity to handle mass casualties, patient isolation systems, laboratory diagnostics for new biologic agents, and the enhancement of command and control structures as well as communication among health and emergency services agencies.
      USDHHS
      HHS announces $1.3 billion in funding to states for bioterrorism preparedness.
      Public health officials became concerned that the singular focus on new threats might overshadow the traditional activities of public health departments and hospitals and weaken their ability to tackle existing challenges.
      • Lurie N.
      • Wasserman J.
      • Nelson C.D.
      Public health preparedness: evolution or revolution?.
      • Staiti A.B.
      • Katz A.
      • Hoadley J.F.
      Has bioterrorism preparedness improved public health?.
      • Smith S.
      Anthrax versus the flu.
      • Cohen H.W.
      • Eolis S.L.
      • Gould R.M.
      • Sidel V.W.
      Hyping bioterrorism obscures real concerns.
      Among the negative effects observed was the diversion of staff in hospitals and public health departments from routine activities to meetings and training sessions on preparedness, and reduced attention to nonbioterror-related concerns. Implementing new preparedness activities while maintaining ongoing activities proved to be a challenge.
      • Lurie N.
      • Wasserman J.
      • Nelson C.D.
      Public health preparedness: evolution or revolution?.
      • Katz A.
      • Staiti A.B.
      • McKenzie K.L.
      Preparing for the unknown, responding to the known: communities and public health preparedness.
      For example, the program to vaccinate health workers against smallpox—one of the most prominent bioterror-preparedness activities—caused many health departments to defer or cancel other core public health activities, because of the burden of program work and the required monitoring for adverse effects.
      • Gouvras G.
      The far-reaching impact of bioterrorism What the European Union is doing regarding deliberate releases of biological/chemical agents based on the events in the U.S..
      CDC
      Household transmission of vaccinia virus from contact with a military smallpox vaccinee—Illinois and Indiana.
      While infectious disease response may have received a boost from preparedness funding, chronic disease programs lost ground because of the diversion of managers' attention.
      • Lurie N.
      • Wasserman J.
      • Nelson C.D.
      Public health preparedness: evolution or revolution?.
      • Staiti A.B.
      • Katz A.
      • Hoadley J.F.
      Has bioterrorism preparedness improved public health?.
      • Smith S.
      Anthrax versus the flu.
      However, not all preparedness funding was earmarked restrictively, and health managers were able to direct some of the preparedness funding to investments such as infrastructure—human resources and communication—which proved to have multiple uses.
      USDHHS
      HHS announces $1.3 billion in funding to states for bioterrorism preparedness.
      • Staiti A.B.
      • Katz A.
      • Hoadley J.F.
      Has bioterrorism preparedness improved public health?.
      As described below, these investments were found to improve both the general functioning of public health departments and hospitals and their ability to handle traditional health threats (Table 1).
      Table 1Selected multiple-use preparedness investments and activities in developing countries
      AreaSample investments and activities
      LaboratoriesNational research laboratories (e.g., Pasteur Institutes)
      Diagnostic technology transfer between developed and developing countries
      Multifunctional district-level laboratories
      National laboratory policies and action plans
      Health information systemsVital registries
      Cause-of-death training and reporting
      Health information system strategic plans
      Demographic surveillance systems
      Human resourcesTraining of epidemiologists, health economists, biostatisticians
      Training of health managers and planners
      Salary support for public health workers
      Paid community health workers connected to health systems
      CommunicationImproved community health education materials
      Websites for public health messages
      Spokespeople for public health information
      Development of locally-relevant information channels (e.g., radio, plays)

      Infrastructure (Laboratories and Health Information Systems)

      Investments in communications, lab capacity, and epidemiologic tools had application to bioterror and pandemic influenza as well as to the broader health system. Examples of such multiple-use investments included radio systems, new computer equipment, improved hospital isolation facilities, and online alert networks.
      • Lurie N.
      • Wasserman J.
      • Nelson C.D.
      Public health preparedness: evolution or revolution?.
      • Staiti A.B.
      • Katz A.
      • Hoadley J.F.
      Has bioterrorism preparedness improved public health?.
      • Katz A.
      • Staiti A.B.
      • McKenzie K.L.
      Preparing for the unknown, responding to the known: communities and public health preparedness.
      There were also improvements in laboratory capacity to handle a variety of biological agents, both bioterror-related and other.
      • Katz A.
      • Staiti A.B.
      • McKenzie K.L.
      Preparing for the unknown, responding to the known: communities and public health preparedness.
      Web-based health information networks that were put in place in response to the 2001 terror attacks, such as New York's health emergency response data system, have been used since to monitor infectious disease outbreaks, track health facility assets, and run simulation exercises.
      • Lurie N.
      • Wasserman J.
      • Nelson C.D.
      Public health preparedness: evolution or revolution?.
      • Gotham I.J.
      • Sottolano D.L.
      • Hennessy M.E.
      • et al.
      An integrated information system for all-hazards health preparedness and response: New York State health emergency response data system.
      Syndromic surveillance, a computerized notification system for patterns of symptoms suggestive of an infectious disease outbreak, was successfully used for nonbioterror diseases in New York City (influenza, rotavirus).
      • Heffernan R.
      • Mostashari F.
      • Das D.
      • et al.
      New York City syndromic surveillance systems.
      Telephone-based syndromic surveillance, using existing telephone health information lines, is being developed in Canada and the United Kingdom (UK).
      • Cooper D.L.
      • Smith G.
      • Baker M.
      • et al.
      National symptom surveillance using calls to a telephone health advice service—United Kingdom, December 2001–February 2003.
      • Moore K.
      Real-time syndrome surveillance in Ontario, Canada: the potential use of emergency departments and Telehealth.
      In Europe, France's Institut de Veille Sanitaire (Institute for Public Health Surveillance), whose mandate was expanded in 2004 in the wake of the European terrorist attacks, collects health information on infectious and other diseases from regional networks and communicates it to the National Ministry of Health and European partners, such as the European Early Warning and Response System (EWRS).
      Institut de Veille Sanitaire
      Mission.
      This infrastructure has had synergies for pandemic influenza preparedness, as the EWRS in turn has been used to focus the EU's response to severe acute respiratory syndrome (SARS) and avian influenza cases in Europe.
      European Commission
      European Commission early warning and rapid alert systems in the field of health threats.

      Human Resources

      Funding for public health human resource development has risen dramatically in the U.S., from under $1 million in 1997 to $100 million in 2003, in large part buoyed by bioterrorism grants.
      • Turnock B.J.
      Roadmap for public health workforce preparedness.
      New staff hired with bioterror funds include preparedness coordinators who have helped to bring a new organizational skill-set to public health departments.
      • Lurie N.
      • Wasserman J.
      • Nelson C.D.
      Public health preparedness: evolution or revolution?.
      Newly hired epidemiologists and statisticians have helped to bolster overall public health surveillance and planning.
      • Katz A.
      • Staiti A.B.
      • McKenzie K.L.
      Preparing for the unknown, responding to the known: communities and public health preparedness.
      New training requirements for emergency preparedness have also provided opportunities to re-examine and update preservice and inservice training curricula for public health workers.
      • Pestronk R.M.
      Why just prepare for emergencies when full use is possible?.
      One important concern raised by public health managers is the sustainability of the funding.
      • Staiti A.B.
      • Katz A.
      • Hoadley J.F.
      Has bioterrorism preparedness improved public health?.

      Communication

      New technologies have strengthened the communication links between facilities (hospitals, laboratories) and public health agencies that were leveraged for broader data-sharing.
      • Lurie N.
      • Wasserman J.
      • Nelson C.D.
      Public health preparedness: evolution or revolution?.
      Similarly, communication among levels of government improved through the systems developed for emergency preparedness.
      • Staiti A.B.
      • Katz A.
      • Hoadley J.F.
      Has bioterrorism preparedness improved public health?.
      Such partnerships have improved coordination among the various actors in responding, for example, to a mass blackout in Cleveland, a TB outbreak in Virginia, and a series of hurricanes in Miami.
      • Katz A.
      • Staiti A.B.
      • McKenzie K.L.
      Preparing for the unknown, responding to the known: communities and public health preparedness.
      • Rendin R.W.
      • Welch N.M.
      • Kaplowitz L.G.
      Leveraging bioterrorism preparedness for non-bioterrorism events: a public health example.
      Public communication also benefited, both through the efforts of the newly hired risk-communication personnel and as a result of heightened public attention to the work of public health agencies.

      Implications for Public Health Systems in Developing Countries

      This experience with health system preparedness in the U.S. and Europe may offer insight into which investments may be particularly useful in improving the capacity of developing countries to respond to emergencies while strengthening their basic public health systems.

      Infrastructure

      Laboratories

      Functional laboratories—well-equipped, -supplied, and -staffed—are essential to delivering quality routine health services and to responding to public health emergencies. Yet in the developing world, even basic laboratory facilities that, according to the WHO, should be able to perform malaria microscopic evaluation and hemoglobin, HIV, and glucose testing are scarce. This is compounded by a lack of diagnostic equipment and trained technicians, weak monitoring, and inconsistent or absent standards for laboratory testing.
      • Petti C.A.
      • Polage C.R.
      • Quinn T.C.
      • Ronald A.R.
      • Sande M.A.
      Laboratory medicine in Africa: a barrier to effective health care.
      • Mundy C.
      • Ngwira M.
      • Kadewele G.
      • Bates I.
      • Squire S.B.
      • Gilks C.F.
      Evaluation of microscope condition in Malawi.
      • Ejilemele A.A.
      • Ojule A.C.
      Knowledge, attitude and practice of aspects of laboratory safety in pathology laboratories at the University of Port Harcourt teaching hospital, Nigeria.
      Ministries of Health are often unaware of the actual (as opposed to “on paper”) functionality of a given laboratory or hospital, making response planning difficult.
      • Ajayi I.O.
      • Olumide E.A.
      • Oyediran O.
      Patient satisfaction with the services provided at a general outpatients' clinic, Ibadan, Oyo State, Nigeria.
      • Pearson L.
      • Shoo R.
      Availability and use of emergency obstetric services: Kenya, Rwanda, Southern Sudan, and Uganda.
      Laboratory-medicine experts have called for major investment in African laboratories, exhorting donors to build within, rather than circumvent the existing laboratory infrastructure to avoid the creation of redundant parallel systems.
      • Petti C.A.
      • Polage C.R.
      • Quinn T.C.
      • Ronald A.R.
      • Sande M.A.
      Laboratory medicine in Africa: a barrier to effective health care.
      While governments recognize the need for investments in laboratories in principle—74% of African countries have a national laboratory policy—these plans have not materialized in many countries, due in part to shortages of financial and human resources.
      WHO/AFRO
      HIV/AIDS laboratory capacity.
      A promising example of the development of laboratory infrastructure is the Pasteur Institutes, a network of research laboratories in 30 developing countries, including some of the poorest countries in Africa: Central African Republic, Senegal, Côte d'Ivoire, Niger, Cameroon, and Madagascar. The Institutes conduct research on locally prevalent infectious diseases, train local scientists, and facilitate technology transfer in laboratory medicine.
      Institut Pasteur International Network
      Mission.
      • Akoua-Koffi C.
      • Kouakou B.
      • Kadjo H.
      • et al.
      [Results of two-year surveillance of flu in Abidjan, Côte d'Ivoire].
      • Bitam I.
      • Baziz B.
      • Rolain J.M.
      • Belkaid M.
      • Raoult D.
      Zoonotic focus of plague, Algeria.
      • Lefeuvre A.
      • Marianneau P.
      • Deubel V.
      Current assessment of yellow fever and yellow fever vaccine.
      • Matsika-Claquin M.D.
      • Massanga M.
      • Menard D.
      • et al.
      HIV epidemic in central African republic: high prevalence rates in both rural and urban areas.
      The international community's focus on AIDS has brought substantial new resources to developing countries, particularly in Africa, and this has also translated into better laboratory capacity. Thus, 90% of African countries responding to a WHO survey reported that they now have the capacity to screen for HIV antibodies at the district level.
      WHO/AFRO
      HIV/AIDS laboratory capacity.
      New investments could expand these laboratories' capacity to diagnose other infectious diseases.

      Health information systems

      Effective surveillance systems are essential to identifying potential outbreaks. While establishing real-time virologic or syndromic surveillance should not be a priority in developing countries, investing in well-functioning health information systems that can be used to communicate epidemiologic as well as administrative data in a timely manner—from the lowest level of the health system to the central ministry of health—is a shared priority area for health system development and emergency preparedness. The need for better health data is great: The WHO estimates that it receives accurate cause-of-death statistics from only 31 of its 193 member states.
      WHO
      Registering births and deaths: the job that no one wants.
      As a result, the WHO has launched a global partnership for improved health information systems, the Health Metrics Network. This network supports developing countries in assessing their health information systems and improving their coverage of vital registration, as well as providing training on international health information standards (e.g., ICD classification). Cambodia, for example, is working with the Health Metrics Network and the Japanese International Cooperation Agency to scan and analyze 11 million birth and death records and to conduct a national census that will, for the first time, include information about mortality and causes of death.
      Health Metrics Network
      Cambodia: getting the measure of public health.
      Countries such as Sierra Leone are undertaking the assessment of health information systems and making 10-year strategic plans for improvement.
      Health Metrics Network
      Sierra Leone: a 10-year health information plan.
      Health information systems could also be used to gather information on the actual (rather than planned) functionality of health posts, centers, and hospitals that would be valuable for a wide range of health planning activities.
      Linking community-level clinics with the health information system would dramatically expand the usefulness of the system for both routine and outbreak epidemiology. As experience has shown with the Demographic Surveillance Systems (DSS) in Bangladesh and in several African countries, with adequate investment it is possible to obtain near real-time information on a community's burden of disease and causes of death in low-income settings.
      • Adjuik M.
      • Smith T.
      • Clark S.
      • et al.
      Cause-specific mortality rates in sub-Saharan Africa and Bangladesh.
      • Baiden F.
      • Hodgson A.
      • Adjuik M.
      • Adongo P.
      • Ayaga B.
      • Binka F.
      Trend and causes of neonatal mortality in the Kassena-Nankana district of northern Ghana, 1995–2002.
      • Adazu K.
      • Lindblade K.A.
      • Rosen D.H.
      • et al.
      Health and demographic surveillance in rural western Kenya: a platform for evaluating interventions to reduce morbidity and mortality from infectious diseases.
      Such systems can provide important information on the prevalence and seasonality of diarrheal illness and on the routine causes of death.
      • D'Souza S.
      A population laboratory for studying disease processes and mortality—the demographic surveillance system, Matlab Comilla, Bangladesh.
      • Tatem A.J.
      • Snow R.W.
      • Hay S.I.
      Mapping the environmental coverage of the INDEPTH demographic surveillance system network in rural Africa.
      Finally, basic information systems need not be expensive. Experience from Tanzania suggests that collecting data on 38 sociodemographic and health indicators (via the census and DSS) costs approximately $0.53 per capita, per year.
      • Rommelmann V.
      • Setel P.W.
      • Hemed Y.
      • et al.
      Cost and results of information systems for health and poverty indicators in the United Republic of Tanzania.

      Human Resources

      Human resource shortages have been called one of the most pressing problems in the health systems of the developing world today.
      Joint Learning Initiative
      Human resources for health: overcoming the crisis.
      • Anand S.
      • Barninghausen T.
      Human resources and health outcomes: cross-country econometric study.
      • Zarocostas J.
      Migration of health workers from less developed countries needs urgent solution, say experts.
      While shortages of clinical staff have received the most attention, there are similar or worse shortfalls in public health personnel.
      Joint Learning Initiative
      Human resources for health: overcoming the crisis.
      • Mosley W.H.
      Population change, health planning and human resource development in the health sector.
      WHO
      World Health Report 2006: working together for health.
      The shortages are exacerbated by low health worker motivation and high attrition, due in part to low wages and poor working conditions.
      • Fritzen S.A.
      Strategic management of the health workforce in developing countries: what have we learned?.
      • Wyss K.
      An approach to classifying human resources constraints to attaining health-related millennium development goals.
      All of these areas are targets for investment. An example of a successful approach is the Malawi emergency human resources program, a 6-year training and salary-improvement program financed by the UK's Department for International Development (DFID). The program aims not only to increase the number of front-line health workers (Malawi has one doctor per 62,000 people) but also to build capacity within the Ministry of Health for better health system management and planning as well as analysis of health data.
      • Palmer D.
      Tackling Malawi's human resources crisis.
      Trained and paid community health workers who are linked to and supported by the health system can also play a vital role in surveillance, communication, and outbreak-control activities.
      • Watts G.
      Bangladesh group has trained 30 000 community health workers.
      WHO
      Strengthening the performance of community health workers in primary health care Report of a WHO study group.
      Training higher-level public health personnel is also important. Pandemic planning requires mathematical modeling of disease and mortality projections and their corresponding impacts on health service utilization, health costs, and other health system process indicators. Such modeling requires epidemiologists and biostatisticians as well as health planners, economists, and administrators. The same people can also perform a wide variety of essential public health tasks, such as monitoring the incidence of priority infectious diseases (e.g., HIV/AIDS) and estimating the impact of seasonal epidemics (e.g., malaria). Health economists can assist countries in estimating the resources required to respond to an emergency and to expand the health system to tackle existing morbidity.
      Health policymakers need training and support to undertake comprehensive human-resource planning, which is critical to both targets. Health human resource planning relies on the sound assessment of current health worker numbers by category as well as the assessment of future inflows, attrition, and geographic distribution.
      • Fritzen S.A.
      Strategic management of the health workforce in developing countries: what have we learned?.
      • Zurn P.
      • Dal Poz M.R.
      • Stilwell B.
      • Adams O.
      Imbalance in the health workforce.
      Gaps in different health worker categories can be identified and strategies for closing these elaborated.

      Communication

      Communicating with the public is a core part of emergency response, and enhanced communication channels can also be used to convey routine health information.
      WHO
      WHO checklist for influenza pandemic preparedness planning.
      The WHO influenza pandemic planning checklist suggests developing websites, leaflets, and fact sheets on topics related to pandemics.
      WHO
      WHO checklist for influenza pandemic preparedness planning.
      The same communication tools could be used for a broad range of health priorities. For example, nearly 40% of urban Ugandan teenagers who attend high school reported looking for health information on the Internet, suggesting that it is emerging as a powerful tool for health education.
      • Ybarra M.L.
      • Kiwanuka J.
      • Emenyonu N.
      • Bangsberg D.R.
      Internet use among Ugandan adolescents: implications for HIV intervention.
      In many developing countries, health education materials for existing diseases, whether for the public or for health workers, are often of low quality, may not be in local languages, and are often outdated.
      • Tarwireyi F.
      Production, distribution and problems experienced with health education materials in two districts of Mashonaland East Province, Zimbabwe.
      Investing in health communication would thus benefit broader health goals.
      Nominating spokespeople to address potential threats, as recommended by the WHO, has been an effective strategy to energize national efforts on HIV, and could be expanded to other diseases.
      WHO
      WHO checklist for influenza pandemic preparedness planning.
      • Levine R.
      Case studies in global health: millions saved.
      Prominent people, whether politicians like Uganda's President Museveni or actors and other celebrities, can be an important catalyst to inform and motivate the public. Investing in improved mass-media campaigns may also be of benefit to both aims. For example, evidence is emerging that focused and locally specific media campaigns can result in the increased use of modern contraceptives.
      • Gupta N.
      • Katende C.
      • Bessinger R.
      Associations of mass media exposure with family planning attitudes and practices in Uganda.
      • Kane T.T.
      • Gueye M.
      • Speizer I.
      • Pacque-Margolis S.
      • Baron D.
      The impact of a family planning multimedia campaign in Bamako, Mali.
      Other promising avenues to communicate health information include the use of soap operas, radio broadcasts, plays, and village informal communication networks, particularly in countries where literacy and access to technology are low.
      • Convisser J.
      Mass media entertainment for AIDS communication in Zaire.
      • Keller S.
      Media can contribute to better health.
      Table 1 is a summary of possible multiple-use investments in developing countries.

      Conclusion

      Concerns about bioterrorism and pandemic influenza have put a spotlight on public health systems across the globe. Experience in the U.S. and other developed countries suggests that preparedness funding, when directed toward multiple-use investments, has strengthened core public health system functions. An exclusive focus on bioterror and pandemic preparedness is inappropriate in developing countries, where underfunded ministries of health often strain to perform routine public health functions. Instead, donor funds for emergency preparedness should be leveraged to strengthen health system fundamentals, such as health information systems, laboratories, human resources, and communication systems, to enable developing countries to better respond both to the current burden of disease and to future pandemics.
      The author would like to thank Christine A. Aguiar for her capable assistance in the preparation of this manuscript.
      No financial disclosures were reported by the author of this paper.

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