#1International Health Regulation-GHSA National Action Planning Experience & Implementation Status Ministry of National Health Services, Regulations & Coordination (#25 Year IHR National Action Plan Pakistan (2017-21) Questions to be Addressed PAKISTAN NATIONAL ACTION PLAN FOR HEALTH SECURITY (NAPHS) A SHARED OPPORTUNITY FOR SUSTAINAB IMPLEMENTATION OF IHR (2005) RAPPOR Objective Planning for Health Security 1. What are the priority areas of implementation and basis of 2. prioritization? Government allocating domestic resources to implement the priorities? 3. Areas needing external 4. support? If already begun implementation, what specific areas have you focused on and what's the status of implementation activities?#3Pakistan (2017-21) 5 Year IHR National Action Plan for Pakistan 0 Health Surity Volume 16, Supplement 1, 2018 Mary Ann Lieben, Inc DOE 10.1089/2018 0072 DEVELOPMENT OF A COSTED NATIONAL ACTION PLAN FOR HEALTH SECURITY IN PAKISTAN: LESSONS LEARNED PAKISTAN NATIONAL ACTION PLAN FOR HEALTH SECURITY (NAPHS) A SHARED OPPORTUNITY FOR SUSTAINABLE IMPLEMENTATION OF IHR (2005) Malik Safi, Kashef Ijaz, Dalia Samhouri, Mamun Malik, Farah Sabih, Nirmal Kandel, Mohammad Salman, Ludy Suryantoro, Ahmad Liban, Hamid Jafari, Assad Hafees and Provincial Partners DRAFT FOR APPO In order to asses progress toward achieving compliance with the International Health Regulations (2005), member states may voluntarily nequea a Joint External Evaluation (JEE). Plan was the first country in the WHO Estem Mediter nean Region to volunteer for and complete a JEE to blish the baseline of the country's public health capacity multiple sectos covering 19 technical area. It subsequently developed a poor-JEE coated National Action Plan for Health Security (NAPHS). The process for developing the coed NAPHS was based on objectives and activities related to the 3 o 5 priority actions for each of the 19 JEE technical areas. Four key lessons were learned during the process of developing the NAPHS. Fist multisectoral coordination at both fedeal and provincial levels is important in a devored health system, where provinces are autonomous from a public health sector standpoint. Second, the development of a cased NAPHS rquines engagement and investment of the country's own caources for inabilty as well as donor coordination among national and international donors and parmes. Engagement from the ministres of Finance, Planning and Development, and Foreign Affair and from WHO was so important. This development of predefined goals, tages, and indications: aligned with the JEE part of the NAPHS process proved to be critical, as they can be used to monitor progress toward implementation of the NAPHS and provide data for repeat JEE Lastly, several challenges were identified related to the NAPHS process and costing tool, which need to be addressed by WHO and panners to help countries develop their plans. Keyword Joint External Evaluation, International Health Regulations, Pakistan, Public health preparedness and response N FERUARY 2016, THE World Health Organization I(WHO) banched a joint Excimal Braduation (EE) with inputs from WHO gons, incorporating various gional and partner initiatives like the Global Health Se- curity Agenda (CHSA) Using the JEE tool, countries conduct a fasement that is followed by an external caluation by a WHO-led multidisciplinary team of ex- pent. After the completion of external caluation, the JEE report is shared with the country for review and published online, and the country is encouraged to lead the development Ministry of National Health Services Regulations & Coordination Dr. Mind De Ad Hawthe Miniery of Nained Health Services Regular and Condon amabad, Paki Dr. K De Humid and maliban all with the ComerforCbbl Hold Ces for Disc Cod and Pervertis Adama Gaja. Dr. Dali Sambour and Dr. Mum Make with the Health Face Prom, WHO E Malismancan Regional, Cairo, Egypt Dr. Farah Sabhi with the WHO Reptive affog blamabad, Pak Dr. Nimal Kandil and Lucy Suyonors are with the WHO Headquates Gen Swineand The Mammad Sales in with the National Inn of Hald bad, Pak Provincial IHR Focal Pain Panjib, Dr. Azim Al KPK, DAB, Dr. Haya Ram Sindhy FATA Dr. Ania Afidi Dr. Salem Memon AJK, Dr. Syed Nadam If GB,Dr. Zakir 5-25#4Development of NAP for Health Security 2nd country in EMRO to develop 5 years IHR NAP TWG outlined NAP priority areas- comprehensive consultative process from Sept till Nov 2016 (6 fed & prov. workshops) IHR NAP endorsed on 1 Dec 2016 Costing exercise completed by May/June 2017 Presentation to IHR Task Force & Donors Coordination Forum to align support PC1s developed to secure domestic funding Implementation of NAPHS in process.....#51-What are the priority areas of implementation and basis of prioritization? Key Recommendations of JEE 1. Critical need for continued and expanded multi-sectoral communication and coordination. 2. Critical need for a sufficiently funded, widely supported country 5-year plan to strengthen IHR capabilities. 3. Need to establish a strong, visible, active surveillance & tiered public health laboratory system 4. Need to develop and enhance regulations, standards, and coordination mechanisms for food safety 5. Need for a national cross-sectoral approach for Anti Microbial Resistance#62-Government allocating domestic resources to Institutions implement the priorities? Areas Cost of PC 1 1 National Institute PHL Network of Health - NPHI IDSR 2 Port of Entries 3 AMR 4 AMR Surveillance Workforce development Core Capacities Public Health Emergency Response Equipment and Infrastructure Human Resources (New Positions) Operational and Logistics Support 7 Strategic priorities PKR 6,718.10 m ($ 50.89 m) PKR 1,644.67 m ($ 11.9 m) PC 1 under development (based on AMR NAP) PKR 62.00 m (Veterinary sector)#7Partners 1 World Health Organization 2 CDC 3 PHE 4 European Union 5 Fleming Fund 6 GAVI Alliance 7 China 8 00 3- Areas needing External support? Additional External Support Requirements Areas of Existing Support AMR & IPC; PH Labs; Zoonosis; Emergency preparedness & response (RRT on all hazard approach); Surveillance system; immunization; POE (IHR compliant rules & regulations); Capacity building for IHR PHL network, EPI, WFD through FETP Program; EOC Real Time Disease Surveillance and response with capacity building Bio-safety & Bio-security AMR surveillance Routine Immunization Strengthen core capacities at selected PoEs Implementation of IDSR Pilot (Phase 1) IHR compliant PoE rules and regulation Functionality of EOC (develop/establish operational mechanism and coordination linkages (all hazards approach)#8IHR Technical Area National legislation policy and financing Coordination and NFP Communications 4. Implementation Status Progress Update KPK enacted public health surveillance Act 2017 National public health Act under drafting process Technical review of existing PoE legislation (for compliance with IHR) Food Safety legislation assessment conducted Designation of focal points (IHR/GHSA NFP; Provincial IHR FP; IHR FP in Ministries of NFS & Climate Change) National multi-sectoral IHR taskforce notified Surveillance and Response Disease prioritization for surveillance IDSRS framework developed (phase-1 to be launched in 2019) Ongoing capacity building on IDSR (reporting, information, DHIS-2, RRT and Labs)#9IHR Technical Area Preparedness Health Workforce Development Laboratory Biosafety & Biosecurity 4. Implementation Status Progress Update All hazards mapping completed at national level Draft of costed pandemic preparedness plan National Public Health EOC established (capacity building of NIH staff) National HRH strategy developed & endorsed Ongoing capacity building on disease surveillance and response (FELTP, RRT. IMS) FELTP transition to NIH (sustainability) Vet lab staffs trained in AMR diagnostics National lab and biosfatey policy & strategic plan developed & endorsed PHL network establishment at provincial level National Lab standards defined Lab networking through LIMS including linkages with vet sector Continuous capacity building (BRM, LQMS,LIMS) Lab simulation exercise planned (30-31 Jan 2019)#10IHR Technical Area AMR Immunization Zoonotic Diseases 4. Implementation Status Progress Update Focal AMR focal points in health & veterinary sectors National multi-sectoral AMR Steering Committee National AMR Strategic Framework & National Action Plan developed & endorsed (Translated into Provincial Action Plan) Ongoing sentinel surveillance (WHO GLASS protocol) Integrated AMR surveillance in OH approach (ESBL Tricyclic project) National Action Plan for XDR Typhoid being developed Secure domestic allocation and donor funding New vaccines (Rota, MR, TCV planned) introduced into RI Enhanced collaboration & inclusion of animal/ livestock, environment sector on different forum (AMR; labs; biosafety & biosecurity; surveillance) Zoonotic disease prioritization completed One Hub established at NIH One Health strategic framework developed#11IHR Technical Area Others 4. Implementation Status Progress Update PoE assessment and existing legislation review Training and capacity building of PoE staff The key success; Costed IHR NAPHS has been now made an integral part of Government s 12th 5 Year Plan (2019-23) - MoPD&R, which approves allocation for all new projects within the Government Sector.#12Linking NAPHS to GPW 13 To save Pakistan from health emergencies and disease outbreaks we need to aaddress health emergencies Goal 2: 40 million more people protected from health emergencies Real time disease surveillance & response Public health lab network • Skilled health workforce SENTRY MK-1 • Functional health establishments at 19 Points of Entry (POEs) with quarantine facilities ↑ ہیلتھ کنٹرول Health Control • Anti microbial resistance . National all hazard multi-sectoral emergency preparedness & response plan . Linkages with other line ministries and WHO#13Summary of total Cost of 5 Year Health Security Plan S Province / No. Federating Unit Total In PKR Total In Dollar Year I Year II Year III Year IV Year V (In Million) In Million 1 Federal 2860.904 785.950 583.318 554.712 447.649 5231.383 112.5278 2 KPK 10613.290 1511.139 1536.871 1100.395 1382.770 16144.467 166.9628 3 Punjab 8989.028 1491.867 1649.408 1291.608 1411.198 14833.110 133.0549 Sindh 4 7786.723 1376.091 1547.312 1110.233 1406.833 13227.193 50.3017 5 Baluchistan 11903.652 1520.946 1474.133 1168.232 1297.172 17364.136 132.4162 6 Fata 9645.741 1098.957 1171.160 916.930 1004.925 13837.714 155.2353 AJK 7 9499.416 599.875 676.862 421.574 505.164 11702.890 142.6261 GB 8 9583.169 1085.310 1175.777 918.547 1008.482 13771.284 127.1845 Total Cost 70881.923 9470.136 9814.842 7482.232 8464.194 106112.177 1020.30#14Area National Public Health Institute Central Health Establishment (PoE) Federal Funding Required - Costed NAP IHR Coordination Technical Support Required Antimicrobial Resistance (AMR)* Biosafety& Biosecurity National Laboratory System Surveillance Reporting Cross border Collaboration MIS Development Capacity Development Updating Legislation Zoonotic Diseases USD in millions 4.02 10.66 61.83 71.27 71.96 17.02 43.19 102.34 MONFS&R (One Health) Mo CC Food safety 46.65 Immunization (mostly -Veterinary Sector) Chemical Events (Environmental monitoring, lab strengthening, capacity building, waste/spills management, poison control centres) 290.24 8798.166 (Based-provincial shares only)#15Gap Analysis of Costing National/ Provinces/ Areas Total Cost Year 1 Year 2 Est. Cost Est. Cost Year 3 Est. Cost Year 4 Year 5 Total Cost Est. Cost Est. Cost PKR (Million) USD (Million) Govt. of Pakistan 18339.943 4891.600 5608.892 4769.460 4712.470 38322.365 368.484 Funding Gap 52541.980 4578.536 4205.950 4205.950 2712.772 3751.724 67789.812 651.825 Total Cost 70881.923 9470.136 9814.842 7482.232 8464.194 106112.177 1020.309#16. Costing Methodology Working sheet of each activity requiring costing has been reflected separately Costing based on following categories: ○ Technical Assistance ○ Equipment Cost ○ Workshops, Trainings, Meetings & Seminar costs ○ Hiring of Staff 。 Civil Work / infrastructure ○ M&E related travel cost#17Costing Methodology Costing Tools were based on customized excel spread sheets; ● ● ● ● All 19 Technical Areas are summarized in one summary sheet Each Technical Area is a separate excel sheet Each activity is also costed separately according to the needs of relevant departments Working sheets are linked with each activity based on costing requirement of the activities Each activity of all technical areas discussed and costing requirement filled in as per their needs#18Challenges Getting attention of Policy makers for domestic resources Skilled human resource Inter-sectoral coordination Pace of implementation in other sectors! Sustained commitment Donor coordination, duplication and funding#19THANK YOU 19#20Components of PC 1 for NIH strengthening Component Estimated Cost in Estimated Cost in Millions of PKR Millions of US$ I. Integrated Disease Surveillance & 2,640.00 Response System 20.00 II. Public Health Laboratories Network 3,073.32 23.28 III. FELTP Transition to FEDSD Grand Total: 1,004.78 7.61 6,718.10 50.89#21POE-PC-1 Components with Cost S.No. Component Estimated Cost in PKR Millions Estimated Cost in USD Millions 1. Strengthening Core Capacities 41.33 0.3 2. Public Health Emergency Response 51.15 0.4 3. Equipment and Infrastructure 512.03 3.7 4. Human Resources 953.98 6.9 5. Operational Support 86.18 0.6 Total PC-1 Cost for Five Years 1,644.67 11.9#22JEE Score (Pakistan) Capacities National legislation, policy and financing Indicators P.1.1 Legislation, laws, regulations, administrative requirements, policies or other government instruments in place are sufficient for implementation of IHR Score¹ 2 Preparedness R.1.1 Multi-hazard National Public Health Emergency Preparedness and Response Plan is developed and implemented 1 P.1.2 The state can demonstrate that it has adjusted and aligned its domestic legislation, policies and administrative arrangements to enable compliance with the IHR (2005) 3 R.1.2 Priority public health risks and resources are mapped and utilized R.2.1 Capacity to activate emergency operations 1 2 IHR coordination, communication and advocacy Antimicrobial resistance P.3.2 Surveillance of infections caused by AMR pathogens P.2.1 A functional mechanism is established for the coordination and integration of relevant sectors in the implementation of IHR. 3 Emergency response operations P.3.1 Antimicrobial resistance (AMR) detection R.2.2 Emergency Operations Centre operating procedures and plans R.2.3 Emergency operations programme 2 3 P.3.3 Healthcare associated infection (HCAI) prevention and control programs P.3.4 Antimicrobial stewardship activities 1 Linking public health and security Authorities R.2.4 Case management procedures are implemented for IHR relevant hazards R.3.1 Public health and security authorities (e.g. law enforcement, border control, customs) are linked during a suspect or confirmed biological event 2 3 P.4.1 Surveillance systems in place for priority zoonotic diseases/pathogens P.4.2 Veterinary or Animal Health Workforce 3 3 Zoonotic diseases Medical countermeasures P.4.3 Mechanisms for responding to zoonoses and potential zoonoses are estab- lished and functional 2 Food safety P.5.1 Mechanisms are established and functioning for detecting and responding to foodborne disease and food contamination. and personnel deployment R.4.1 System is in place for sending and receiving medical countermeasures during a public health emergency 4 2 R.4.2 System is in place for sending and receiving health personnel during a public health emergency P.6.1 Whole-of-Government biosafety and biosecurity system is in place for hu- Biosafety and biosecurity man, animal, and agriculture facilities 2 R.5.1 Risk communication systems (plans, mechanisms etc.) P.6.2 Biosafety and biosecurity training and practices 2 R.5.2 Internal and partner communication and coordination 2 P.7.1 Vaccine coverage (measles) as part of national program 2 Immunization Risk communication R.5.3 Public communication 2 P.7.2 National vaccine access and delivery 4 D.1.1 Laboratory testing for detection of priority diseases 4 National laboratory system D.1.2 Specimen referral and transport system 3 R.5.4 Communication engagement with affected communities R.S.5 Dynamic listening and rumour management 2 3 D.1.3 Effective modern point of care and laboratory based diagnostics 2 D.1.4 Laboratory Quality System 2 PoE.1 Routine capacities are established at PoE. 2 Points of entry (PoE) D.2.1 Indicator and event based surveillance systems 3 PoE.2 Effective public health response at Points of Entry 2 D.2.2 Inter-operable, interconnected, electronic real-time reporting system 2 Real-time surveillance D.2.3 Analysis of surveillance data 2 Chemical events CE.1 Mechanisms are established and functioning for detecting and responding to chemical events or emergencies 2 D.2.4 Syndromic surveillance systems 4 D.3.1 System for efficient reporting to WHO, FAO and OIE 2 CE 2 Enabling environment is in place for management of chemical events 2 Reporting D.3.2 Reporting network and protocols in country 2 D.4.1 Human resources are available to implement IHR core capacity requirements 3 RE.1 Mechanisms are established and functioning for detecting and responding to radiological and nuclear emergencies 5 Workforce development D.4.2 Field epidemiology training programme or other applied epidemiology training programme in place Radiation emergencies 3 RE.2 Enabling environment is in place for management of radiation emergencies 5 D.4.3 Workforce strategy 2#23Strategic Goals (2019-23) aligned to GPW 13 1: Advancing universal health coverage Goal: 42 million more people benefitting from UHC 2: Addressing health emergencies Goal: 40 million more people protected from health emergencies 3: Promoting healthier populations Goal: 40 million more people enjoying better health and well-being 4: Corporate Goal: More effective & efficient public health sector in Pakistan 23#24• National: Requirements for Implementation of NAPHS Endorsement of NAPHS by National IHR Taskforce Secure funding for NIH :GHSA-NFP and POES strengthening through PC 1's • Secure funding by Line Ministries: FS&R and Climate change • Draft Public Health Act (s) submitted Securing Technical Assistance and Coordination with donors/partners for resource mobilization Consensus building, implementation and monitoring of NAPHS to meet core capacities Provincial: • Prioritization of technical areas for strengthening Resource mobilization through PC 1 Utilization / Linkages between EOC(s)/DSRU for IHR implementation Partners: Technical and Financial assistance#25Role of MOFS&R & Climate Change MOFS&R ; One health Hub - MOU susaintanability Domestic funding for Laboratories, Surveillance Reporting and AMR Coordination with Provincial Line Departments Laws / Acts MoClimate; Focal Points to be nominated for IHR &AMR Domestic Funding for Lab & Surveillance Coordination with Provincial EPA s for resource mobilization Laws/Acts#26NIH - Key Areas of Strengthening Establishment of IDSR Coordination Unit with - Computers and servers, Technical staff, Trainings, Reporting linkage with provincial DSRUS Strengthening of PHLD to BSL III level lab for PHLN - Upgradation of laboratory, Technical support to 10 regional/provincial labs, Staff capacity building, Linkage with FEDSD for Disease Surveillance related lab testing support) FELTP transition - - Infrastructure (Hostel), HR workforce development (first 2 years in collaboration with HSA), Equipment#27Components of PC 1 for NIH strengthening Component Estimated Cost in Estimated Cost in Millions of PKR Millions of US$ I. Integrated Disease Surveillance & 2,640.00 Response System 20.00 II. Public Health Laboratories Network 3,073.32 23.28 III. FELTP Transition to FEDSD Grand Total: 1,004.78 7.61 6,718 50.89#28AMR Progress Tricycle Project for AMR Surveillance (ESBL E. coli) ongoing and expanding Fleming Fund supporting AMR surveillance, RFPs posted and awaiting award after technical evaluation • AMR reflected in ongoing XDR Typhoid Response plan developed by NIH with WHO/CDC support However, additional support required to fully implement NAPHS activities#29• • AMR- Requirement vs Pledged Technical Support CDC Atlanta - USD 1M/year, funding activities for identified gaps Fleming Fund - GBP 3.2M in phased disbursement linked to deliverables Public Health England - TAs for establishing IDSR-AMR links, amount allocated for TAs not known European Union CoE CBRN - TAs for relevant areas, amount allocated for TAs not known Provinces & Regions Federal AJK GB FATA Punjab Sindh B'stan KP TOTAL AMR 155.725 89.0358 80.7808 114.6358 265.5958 85.7908 99.2308 218.5458 1109.3406#30PoE Progress • WHO mission for reviewing legislation • JSI support for developing PC-1 in light of JEE gaps and NAPHS activities • Infrastructure, HR, planning and operational requirements addressed in PC-1 • PC-1 awaiting submission to planning.#31PoE - Key Areas for Strengthening Improved coordination among health & other partners Develop package of rules for all types of PoEs Additional HR for PoEs, address existing gaps in monitoring and supervision & capacity building of PoEs staff Develop and implement SoPs for one health response, provide operational support for implementation Review and update public health contingency plan. Establish e-reporting system • Equipment including thermal scanners • Construction of quarantine hospitals and PoEs#32IDSR Progress Consensus based IDSR mechanism defined and approved with support of PHE Provinces where an existing IDSR system was in place, mechanism supplements or modifies as per local need Engagement mechanism to include private laboratory networks and para-statals being evolved KPK IDSR system in advanced stage of development, Sindh work to be initiated shortly (latter will have a tentative budget of PKR 110 Million#33Cost of 3 major components of IDSRS pilot in KPK Capital cost of project DESCRIPTION Year 1 Year 2 Year 3 Total Develop and strengthen the institutional mechanism for disease surveillance and response by establishing robust, networked coordination arrangements across provincial and district level. 132.79 109.25 113.99 Million Million Million 356.03 Million Coordinated and timely collection, collation, reporting, analysis and interpretation of disease notification data for effective communicable disease control Strengthening system for appropriate and timely response to outbreaks of epidemic prone diseases by ensuring all support functions of surveillance and response are undertaken 76.17 Million 13.95 13.35 103.47 Million Million Million 106.64 Million 41.06 41.06 188.76 Million Million Million TOTAL 315.6 Million 164.26 168.4 648.26 Million Million Million#34• Challenges & Lessons Learned Donor Coordination is difficult, incomplete information about activities causes duplication • JPRM should be developed in coordination with Health Ministry to better allocate scarce resources Alignment of country priorities and requirements should be reflected in partner / donor plans Coordination mechanism between implementing ministries and line departments has to be clearly elucidated and followed Advocacy with national planning authorities to be initiated early to include financial requirements in overall national plans#35Technical Areas 5 year IHR/GHSA Costed Action Plan (in USD) Provinces & Regions National Legislation IHR Coordination Federal 71.98 AJK GB FATA 41.7 41.7 44.02 37.23 Punjab Sindh B'stan KP TOTAL 37.135 77.84 50.34 40.325 405.04 28.28 30.185 26.99 65.475 89.775 71.895 68.5 418.33 AMR Zoonotic Disease Food Safety 155.725 89.0358 80.7808 114.6358 265.5958 85.7908 99.2308 218.5458 1109.3406 276.03126 1345.58908 1108.13908 1417.53632 1789.24708 1299.58876 1821.14484 1584.59476 10641.87118 353.3007 276.646 276.646 281.646 150.216 405.9224 1553.79686 1553.79686 4851.97082 Biosafety & Biosecurity 96.88 557.945 352.115 555.295 1349.295 2087.699 1255.295 175.91 6430.434 Immunization 215.305 2747.315 5247.315 5247.315 3437.315 2796.68 5247.315 5247.315 30185.875 NLS 99.845 499.45284 517.47684 216.987 2052.32424 803.2218 1287.71 1935.275 7412.29272 Surveillance Reporting 230.29964 947.47368 947.47368 972.99632 1257.54668 1000.95632 1208.6906 918.72904 7484.16596 33.86 199.41638 199.41638 200.57638 246.22138 316.57188 204.32138 370.62688 1771.01066 Workforce Development 56.021 2210.74874 2210.74874 2210.74874 410.74874 1181.18012 2210.74874 1181.18012 11672.12494 Preparedness 577.2652 1122.075 1122.075 1122.075 829.425 1455.455 829.425 1325.505 8383.3002 Emergency Response 148.49 30 30 21 360 170.6552 105 65 930.1452 Linking PH & Sec Agencies 50.7136 11.352 11.352 11.352 9.78 13.332 11.352 11.352 130.5856 Med CM & Prsnnl Deplyt 118.3 14.75 14.75 14.75 78.74 64.465 15.97 15.97 337.695 Risk Communication 57.16632 54.90616 54.90616 54.90616 80.80616 57.40616 80.80616 120.80616 561.70944 POE 2652.978 251.02 251.02 1275.1841 Chem Events 0 1275.1841 Radiation Events 0 0 TOTAL 5231.39072 11702.88978 13771.28378 49.7 1044.7 36.513 103.395 103.395 4492.721 1275.1841 1273.0641 1284.15 1207.7 1207.7 8798.1664 0 0 95.475 13837.71382 14833.11018 13227.20244 0 0 17364.13638 0 16144.5266 95.475 106112.2537