This chapter evaluates the role of pandemic preparedness and response indices in appraising global readiness for health crises, with particular attention to the gaps exposed by COVID‑19. It starts by providing a detailed analysis of six of the most commonly used preparedness indices, including their strengths and weaknesses. It then assesses their ability to predict performance, measured using percentage changes in life expectancy between 2019 and 2021, for 51 OECD, European Union/European Economic Area, and Group of 20 countries. The resulting analysis allows to determine which indices most accurately reflected actual preparedness and performance. The chapter also emphasises the importance of considering social, economic, and institutional vulnerabilities in preparedness indices, which are often overlooked but have a significant impact on pandemic response. The chapter concludes with recommendations for improving these indices to improve future pandemic preparedness and response.
The Economic Case for Pandemic Preparedness and Response
Abstract
Key messages
Pandemic preparedness and response are essential public health functions
Given the global public health threat posed by pandemics, it is crucial to improve pandemic preparedness and response. Pandemic preparedness and response encompass actions aimed at effective readiness for responding to disease outbreaks, focussing on prevention policies, and mitigation programmes to minimise susceptibility to risks.
Indices are a useful tool to evaluate a country’s preparedness for pandemics, reflecting response capacities and pandemic impacts
To better prepare for future health threats, it is important to assess how well countries can detect and respond to outbreaks.
Indices enable countries and decision makers to identify capacity strengths and weaknesses, benchmark against other countries and efficiently allocate resources, maintain transparency and accountability. Further, they help to detect early threats, advance policy development, and foster global health security and strengthen international collaboration, since pandemics cannot be managed only at the national level.
The COVID‑19 pandemic revealed that there are still gaps and indices have not managed to fully capture the key dimensions of preparedness
An assessment of six widely used pandemic preparedness and response indices developed pre‑pandemic highlight that most indices are biased in favour of countries with more resources and certain characteristics, including political systems and trust, specific cultures and demographic attributes. This lack of contextualisation and inability to account for dynamic response capabilities creates biases in benchmarking. Further, existing indices are likely founded on lessons learned from past pandemics and are subject to data constraints that likely affect reporting. Also, indices often leave out essential political and governance issues.
The States Parties Annual Report (SPAR) and Infectious Disease Vulnerability Index (IDVI) indices showed stronger correlations with changes in life expectancy during COVID‑19 compared to the INFORM Risk Index and the Epidemic Preparedness Index (EPI), largely due to their focus on factors directly relevant to managing infectious disease outbreaks (public health communication, adhering to international health regulations (IHR) and addressing structural vulnerabilities).
During the COVID‑19 pandemic, countries with higher social vulnerability faced increased mortality rates
Measuring population vulnerabilities is crucial for understanding how underlying risks and weaknesses influence a country’s pandemic preparedness and response. Measures of vulnerability against disasters encompass health, economic, social, institutional, or deferential, and cognitive or communicative dimensions. Understanding the indicators of vulnerability can help policymakers better manage pandemics in these communities.
While some preparedness indices failed to predict certain outcomes of the COVID‑19 pandemic, they remain crucial for international benchmarking
There are a range of ways to strengthen indices for future pandemics. For example, future indices should include fixed characteristics of countries and a range of population vulnerabilities. Future indices should also include sociopolitical and governance variable as they have a large effect on outcomes during a pandemic. Other characteristics that should be highlighted include aspects related to international collaboration and the inclusion of biological and environmental risks. Finally, it is essential that the capacity to mobilise rapidly is included due to the dynamic nature of pandemics.
Pandemic preparedness and response is an essential public health function that address the actions needed to ensure effective readiness for disease outbreaks (Fatiregun and Isere, 2017[1]). Broadly, pandemic preparedness and response is defined as “having the knowledge, capacities, and systems that work to reduce vulnerability and enhance resilience” (World Health Organization, 2023, p. ix[2]). Pandemic preparedness and response enables countries to focus more effectively on prevention policies and mitigation programmes, thereby minimising their susceptibility to threats. It also involves the government’s ability to anticipate (and mitigate) a potential global public health emergency by developing necessary knowledge and capacities. This includes everything from the comprehension of the hazards, the building of capacities for risk foresight and assessment, and the establishment of risk management protocols (OECD, 2022[3]).
Pandemic preparedness and response indices are used to identify deficits in preparedness. Over the years, many indices have been developed to measure how health systems and countries are able to respond to pandemics. Each pandemic preparedness and response index measures various aspects of a country’s ability to effectively combat the pandemic and protect their citizens, though indicators used in each index often vary. Pandemic preparedness and response indexes identify strengths and gaps, which in turn, can help guide how resources are allocated and policies are developed, support accountability mechanisms, and enhance global health security.
However, the COVID‑19 pandemic revealed that there are still gaps and indices have not managed to fully capture the key dimensions of preparedness. Despite high rankings, many countries experienced severe COVID‑19 burdens, highlighting gaps in our understanding of why these indices failed to provide accurate assessments. There is a need to strengthen indices for future pandemics, which requires an examination of the factors they overlooked, such as population vulnerabilities and intangible aspects like public trust and perception during a health crisis.
Pandemic preparedness and response indexes are often structured around cycles of disruption, each phase representing distinct preparedness activities and responses (Box 6.1). This chapter focusses on the early phases of an emerging epidemic outbreak. The first stage (Figure 6.1), “prepare” involves a government’s ability to anticipate and ready itself for a potential pandemic, building knowledge and creating risk management protocols for sectors like the pharmaceutical industry (OECD, 2022[3]). Following an outbreak, the “absorption” stage begins, where governments actively respond to the crisis. This stage aims to reduce the impact on public health, welfare, and the economy. During the early absorption phase, governments implement non-pharmaceutical interventions (NPIs) like lockdowns, school closures, and workplace adjustments to slow the virus’s spread, until vaccines become available to the public (OECD, 2023[4]).
Resilience goes beyond crisis preparedness; it enables systems to absorb shocks and recover swiftly. The disruption cycle aligns with the resilience framework, offering a structured approach to understanding the impact of events like pandemics on systems and communities. This cycle includes four stages – prepare, absorb, recover, and adapt – and highlights the importance of proactive over reactive measures (Figure 6.1). Pandemic preparedness and response indices, developed alongside resilience frameworks, aim to assess how well countries can respond to these stages in the event of a crisis. This framework captures the range of resilience activities, enabling the assessment of strengths and weaknesses in pandemic response. Each phase involves specific actions, such as planning and capability enhancement in preparedness, and risk mitigation in adaptation. Effective indices should therefore evaluate the impact of policies across all phases of the disruption cycle. (The recent OECD report, “Ready for the Next Crisis? Investing in Health System Resilience” (2023[4]) provides more detailed information on the OECD resilience framework).
Note: The examples shown in the figure are illustrative rather than exhaustive and may vary according to the characteristics of the outbreak and the wider context.
Source: Adapted from Kachali et al. (2022[5]), Are preparedness indices reflective of pandemic preparedness? A COVID‑19 reality check, https://doi.org/10.1016/j.ijdrr.2022.103074; Kentikelenis and Seabrooke (2021[6]), Organising knowledge to prevent global health crises: a comparative analysis of pandemic preparedness indicators, http://doi.org/10.1136/bmjgh-2021-006864; Fakhruddin, Blanchard and Ragupathy (2020[7]), Are we there yet? The transition from response to recovery for the COVID‑19 pandemic, https://doi.org/10.1016/j.pdisas.2020.100102; OECD (2023[4]) Ready for the Next Crisis? Investing in Health System Resilience, https://doi.org/10.1787/1e53cf80-en; OECD (2022[3]). First lessons from government evaluations of COVID‑19 responses: A synthesis, https://doi.org/10.1787/483507d6-en.
The increasing risk of pandemics underscores the need to better understand pandemic preparedness and response and develop relevant policy indicators (Jeanne et al., 2023[8]; Oppenheim et al., 2019[9]). The risk of pandemics has risen due to globalisation, environmental degradation, urbanisation, and increased human-wildlife interaction. Globalisation accelerates disease spread through increased travel, trade, and livestock farming, while factors like population growth and climate change are expected to further exacerbate the threat (please see the OECD publication on environmental health and strengthening resilience to pandemics (2023[4]) for more information). COVID‑19 had a profound global impact, and it serves as a reminder of the potential for future pandemics.
Acknowledging these gaps, this chapter begins by explaining the importance of pandemic preparedness and response indices, detailing how they function and their significance. Then, this chapter provides an in-depth review of six indices that were developed before COVID‑19, designed to compare general preparedness across multiple dimensions globally. These indices are evaluated based on their ability to predict performance, measured by the percentage change in life expectancy from 2019 (pre‑COVID‑19) to 2021 (post-initial-COVID‑19 impact). Rather than ranking countries, the focus is on identifying which indices most accurately reflect pandemic performance, a critical factor in assessing preparedness. This chapter also explores indicators used to evaluate vulnerability within pandemic preparedness and response frameworks, highlighting their strengths and limitations. Special focus is given to how these indices capture social, economic, and institutional vulnerabilities, which significantly affect outcomes but are often overlooked. Next, the chapter explores indicators used to evaluate vulnerability in the context of pandemic preparedness and response and concludes by identifying areas for improvement and offering recommendations for enhancing pandemic preparedness and response.
6.2.1. Why and how is a country’s ability to respond to an emerging pandemic measured?
Assessing a country’s ability to prepare helps identify gaps in healthcare and public health systems and evaluate its capacity to quickly detect, contain, and mitigate the spread of epidemics. This ensures timely and effective responses, reduces the impact on public health and the economy, and strengthens global efforts to prevent future outbreaks. By understanding these capabilities, governments can develop policies to improve resilience and readiness for future pandemics. Specifically, well-designed and effective pandemic preparedness and response indices can support decision makers by helping them to:
Detect early threats and allocate resources effectively: Help countries improve ability to detect and respond to emerging threats, enabling more effective disease control (Brainard et al., 2023[10]). Indexes may also provide governments, international organisations and nongovernmental organisations (NGOs) a means to prioritise resource allocation for pandemic preparedness and response initiatives (Ravi et al., 2020[11]).
Benchmark against other countries and promote accountability: Allow countries to measure their preparedness against global standards and compare their performance with other countries (Brainard et al., 2023[10]), promoting the sharing of best practices and collaboration in pandemic response (Goniewicz et al., 2023[12]). This standardised framework would also promote governments’ accountability for their preparedness efforts (Falk et al., 2023[13]), with transparency being essential to maintaining public trust in government and public health authorities (Grabar-Kitarović and Phumaphi, 2023[14]). Further, benchmarking allows countries to identify strengths and weaknesses in their capacities to advance policy development. Provide a framework for evaluating a country’s ability to prevent, detect, and respond to pandemics. Through the assessment of diverse indicators, indices facilitate the identification of both strengths and areas requiring enhancement within a country’s public health infrastructure (World Health Organization, 2023[15]).
Contribute to global security and collaboration: Promote the exchange of best practices, lessons, and resources among nations to collectively strengthen global health security (Ravi et al., 2020[11]). Also promote international exchange of experiences and collaboration by establishing a common language and framework for discussion (Jit et al., 2021[16]).
Effective pandemic preparedness and response and response efforts require an understanding of how communities and systems are structured in relation to disease transmission and the specific vulnerabilities of different populations. Since the replacement of the World Health Organization’s (WHO) International Health Regulations (IHR 1969) in 2005 (enforced from 2007), significant efforts have been made to quantify overall risks and evaluate the vulnerabilities of diverse populations at national, regional, and global scales (Box 6.2). For example, following the commencement of the IHR, countries were required to annually self-report their compliance with the IHR using the online IHR Monitoring Tool (IHRMT), with the outcomes of these evaluations documented in the States Parties Annual Report (SPAR).
Last updated in 2005, the WHO’s International Health Regulations (IHR) serve as a legal framework aimed at preventing, protecting against, controlling, and responding to the international spread of epidemic diseases and management of emergencies. The IHR mandates countries to establish preparedness plans for public health crises and regularly assess and update them. Effective preparedness plans require not only technical and expert guidance, but also clear legal and governance arrangements that enable timely activation of response measures, including well-defined decision-making processes and responsibilities across relevant authorities. The IHR is the sole international legal treaty empowering the WHO to function as the primary global surveillance system.
The IHR can be utilised to evaluate a country’s readiness for pandemics, with countries required to annually self-report their compliance with the IHR using the online IHR Monitoring Tool (IHRMT). Countries report on eight core capacities, encompassing legislation, policy, co‑ordination, surveillance, response, preparedness, risk communication, human resource capacity, and laboratory capabilities, across four hazard categories: zoonotic events, food safety events, chemical events, and radiation emergencies. The outcomes of these evaluations are collected in the States Parties Annual Report (SPAR) and/or the Joint External Evaluation (JEE) Tool, both discussed later in this Chapter.
There are challenges inherent in implementing the IHR and managing disease outbreaks on a global scale. One factor contributing to these challenges is resource constraints, as the IHR requires member states to have the necessary resources for prompt detection, assessment, notification, and reporting of disease outbreaks, yet many states lack these resources, resulting in delays in response and increased risk of uncontrolled spread. Additionally, there exists a significant imbalance in costs and benefits between the state where the outbreak originates and other states, with the affected state bearing the burden of allocating resources to comply with IHR surveillance requirements and combat the disease, potentially leading to adverse economic consequences such as decreased tourism and international trade; however, successful containment of the disease within the affected state benefits all other states.
Source: World Health Organization (2022[17]) Joint external evaluation tool: International Health Regulations (2005), third edition, https://www.who.int/publications/i/item/9789240051980; Sohn et al. (2021[18]), The problems of International Health Regulations (IHR) in the process of responding to COVID‑19 and improvement measures to improve its effectiveness, https://doi.org/10.35500/jghs.2021.3.e18; Broberg (2020[19]), A Critical Appraisal of the World Health Organization’s International Health Regulations (2005) in Times of Pandemic: It Is Time for Revision, http://doi.org/10.1017/err.2020.26
6.2.2. Pandemic preparedness and response indices are important to understand national health security
Pandemic preparedness and response are most often measured with indices that assess, compare, and are intended to enhance a country’s ability to combat disease outbreaks. Numerous institutional and academic indices have emerged to gauge a country’s pandemic preparedness and response, reflecting response capacities and pandemic impacts, and serving as tools to assess and enhance readiness. These indices facilitate the evaluation of national health security and help to bolster international capabilities in pandemic response. In this chapter, six indices are evaluated, including the: Epidemic Preparedness Index (EPI), Global Health Security Index (GHSI), Infectious Disease Vulnerability Index (IDVI), INFORM Risk Index, Joint External Evaluation (JEE) and the IHR State Party Self-Assessment Annual Report (SPAR). Note that although the INFORM Risk Index was not originally designed to measure pandemic preparedness and response, it was quickly adapted for this purpose and became widely used during the COVID‑19 pandemic; it is therefore included in this chapter. The included indices were developed prior to the COVID‑19 outbreak, enabling international comparisons and assessing general preparedness across multiple dimensions, rather than focussing on a single aspect. A summary of all mentioned indices is provided in Table 6.1. In the EU context, other relevant tools also exist, including the Public Health Emergency Preparedness Assessment (PHEPA), carried out by the European Centre for Disease Prevention and Control under Regulation (EU) 2022/2 371 and drawing partly on the SPAR questionnaire.
Notes: * The second edition of SPAR was released in 2021, featuring 15 capacities and 35 indicators, compared to 13 capacities and 24 indicators in the first edition. As this table is used to demonstrate the performance of the indices prior to COVID‑19, the first edition of the tool is reported. IHR = International Health Regulations; POE = Points of entry; NFP = National IHR Focal Point – Contacts designated by each State Party serve as the national centre for IHR communications with the WHO IHR contact points. Indicators regarding points of entry may indicate a collaborative plan or agreement between the public health system and border control authorities to identify suspected and potential cases among international travellers, as well as to trace and quarantine their contacts during a public health emergency (World Health Organization, 2022[17]).
Source: Oppenheim et al. (2019[9]), Assessing global preparedness for the next pandemic: development and application of an Epidemic Preparedness Index, http://doi.org/10.1136/BMJGH-2018-001157; Ravi et al. (Ravi et al., 2020[11]) The value proposition of the Global Health Security Index, http://doi.org/10.1136/bmjgh-2020-003648; Moore et al. (2017[20]) Identifying Future Disease Hot Spots: Infectious Disease Vulnerability Index, www.rand.org/t/RR1605; Inter-Agency Standing Committee and European Commission (2024[21]), INFORM REPORT 2024: 10 years of INFORM, https://data.europa.eu/doi/10.2760/555548; World Health Organization (2022[17]), Joint external evaluation tool: International Health Regulations (2005), third edition, https://www.who.int/publications/i/item/9789240051980; World Health Organization (2021[22]), International Health Regulations (2005): States Parties Self-assessment annual reporting tool, second edition, https://www.who.int/publications/i/item/9789240040120; World Health Organization (2018[23]), International Health Regulations (2005): Guidance document for the States Parties self-assessment annual reporting tool, https://www.who.int/publications/i/item/9789240040120.
Different methods of assessing preparedness have their strengths and limitations. Three of the six methods use third-party evaluations rather than solely relying on a country’s self-assessment, which can reduce bias in reporting. For example, the GHSI uses secondary data from national reports and global databases to evaluate policy and healthcare system readiness (methodology details are in Annex 6.A). Similarly, the WHO’s Framework for Economic Vulnerabilities and Risks to Pandemics (FEVR) measures economic resilience post-pandemic (see Box 6.3). Methods like the JEE, which involve external evaluations and use open-source data, support transparency and inter-country data sharing (detailed in Annex 6.B). While such assessments provide contextual insights and credibility to the assessment, they are often time‑ and resource‑intensive (Oppenheim et al., 2019[9]). In contrast, indices based on self-reported data can be susceptible to information bias, as countries may interpret survey questions differently due to cultural differences or unclear wording, potentially affecting data accuracy and validity.
In October 2021, the G20 established the Joint Finance and Health Task Force (JFHTF) to strengthen global co‑ordination between finance and health sectors for pandemic prevention, preparedness, and response. The initiative also aimed to assess health, social, and economic vulnerabilities associated with pandemics. To achieve this, the Task Force, in collaboration with the WHO, World Bank, IMF, and European Investment Bank, developed the Framework for Economic Vulnerabilities and Risks (FEVR). FEVR integrates data across health, social, and economic domains to support policy dialogue and guide investments in preparedness. Recently, a joint publication by the OECD, WHO, and World Bank applied this framework through integrated modelling, simulating pandemic scenarios to evaluate the impact of different response strategies and the benefits of investing in preparedness, drawing on experiences from COVID‑19, Spanish flu, SARS, and swine flu. For more details, please refer to the source below.
Source: World Health Organization et al. (2023[24]), Report on Economic Vulnerabilities and Risks to Pandemics and Potential Policy Measures, https://g20.in/content/dam/gtwenty/gtwenty_new/document/aug_docs/2_new_G20_Report_FEVR_Paper2Report.pdf; OECD/WHO/The World Bank (2024[25]), Strengthening pandemic preparedness and response through integrated modelling, https://doi.org/10.1787/5f046115-en.
Pandemic preparedness and response indices employ diverse methodologies to assess a country’s ability to prevent, detect, and respond to future pandemics. The six tools presented in Table 6.1 utilise a combination of secondary and self-reported data in their development. These indices vary in the number of categories used to evaluate pandemic preparedness and response, ranging from three in the INFORM Risk Index to seven in the GHSI and IDVI, and 15 in the SPAR. Comparison of the indices indicator by indicator was not possible given the high number, however, the indicators used to evaluate each index often overlapped. The six indices measured 11 “index themes” presented in Table 6.2, which were created to clarify and compare the aspects of preparedness each index covered. Main conclusions from Table 6.2 include:
The indices collectively cover common themes related to pandemic preparedness and response, with unique priorities across indices. Pandemic preparedness and response indices collectively cover a broad spectrum of themes, with overlaps in core areas such as healthcare capacity, infrastructure, and response capabilities, including indicators like healthcare access, epidemiology workforce, and financing for pandemic response. Yet, each index, emphasises certain themes based on its unique focus and purpose. For example, the IDVI was developed to capture vulnerabilities within both health systems and populations, so it thoroughly covers vulnerable populations but may overlook aspects like public health communication.
Preparedness indices address common themes but vary in scope and depth, particularly in addressing vulnerable populations. While pandemic preparedness and response indices share common themes, their scope and depth of coverage vary significantly, particularly regarding vulnerable populations and coping capacity. The GHSI, JEE, and SPAR are the most comprehensive, each covering 10 of the 11 index themes, respectively, including healthcare infrastructure, economic resources, risk communication, and surveillance, with substantial detail. However, the GHSI and JEE lack data on vulnerable populations and coping capacity, which considers understanding the at-risk groups and the assessment of their ability to handle crises. Indicators like literacy rates, refugee populations, undernourishment, and gender equality, which are crucial for understanding vulnerabilities, are often neglected. In contrast, the IDVI, with its narrower scope, excels at capturing health disparities and vulnerabilities.
Co‑ordination and governance are key themes but are emphasised differently across indices. Most indices strongly emphasise governance and political co‑ordination, assessing national frameworks and legislative support for effective responses. However, the focus varies from local to national to international perspectives. The GHSI, IDVI, JEE, and SPAR assess compliance with international norms, particularly IHR-related hazards and border health. Compliance with international norms is understandably a priority for the JEE and SPAR, as both were developed by the WHO under the framework of the IHR. This is why they emphasise IHR standards, whereas other indices may focus more on domestic health capacities. Indicators used to evaluate this theme commonly include participation in international agreements, IHR reporting, and cross-border agreements. It is worth noting that indices less focussed on international compliance may excel in other areas. For example, INFORM, while placing less emphasis on international norms, is strong in evaluating biological and environmental risks beyond pandemics – an area less prioritised by EPI, GHSI, and IDVI.
Note: 1. IDVI had communication strategies measured by number of televisions, cell phones and internet users, but not specifically for public health measures.
1. Human conflict was measured in the INFORM.
IHR = International Health Regulations; POE = Points of entry; NFP = National IHR Focal Point – Contacts designated by each State Party serve as the national centre for IHR communications with the WHO IHR contact points.
Source: See Table 6.1.
Understanding which indices best predicted country performance during COVID‑19 is crucial for improving preparedness for the next pandemic. This section compares indices to identify those that most effectively capture a country’s ability to contain the detrimental effects of the pandemic on population health. Such an analysis is vital for preparing for future pandemics, as it identifies the crucial elements underpinning effective preparedness. The performance of the index is assessed by considering the per cent change in life expectancy from 2019 (pre‑COVID‑19) to 2021 (post-initial-COVID‑19 shock). Changes in life expectancy were scaled to each country’s baseline age expectancy, allowing for fair comparisons by reflecting the proportional impact of the pandemic. Life expectancy was chosen as the performance indicator because it captures both direct and indirect health impacts and due to its wide availability across countries. It reflects mortality from COVID‑19 and the broader strain on healthcare systems, including effects on non-COVID-related health outcomes. Additionally, life expectancy accounts for longer-term consequences like excess deaths and health system resilience, offering a robust measure that supports the assessment of the indexes over multiple preparedness dimensions and is less influenced by data-reporting differences or testing capacity.
The goal was not to rank countries but to determine which indices most accurately captured pandemic performance. Fifty-one countries (OECD, EU/EEA, and G20 members) were ranked into quintiles for each index in Table 6.3. Rankings were normalised based on the total countries assessed in each index (e.g. GHSI and IDVI: 195 countries; INFORM: 191; SPAR: 175; EPI: 188; the JEE index was excluded due to limited comparability, as each country receives an individual report with scores assigned to specific technical areas rather than an overall ranking). This rank-based approach provided a clear view of relative performance, standardising differences across baseline health outcomes. As such, a country with a score of 1 on an index is in the highest quintile (lightest blue in Table 6.3), indicating it was predicted to be among the most prepared, while a score of 5 indicates the lowest quintile (darkest blue in Table 6.3), or least prepared. Note that the quintile rank is derived from the entire assessment, including countries not listed in the table as they fall outside the scope of this work. In Table 6.3, green shading denotes an average index score closer to 1 or a positive change in life expectancy (scaled to each country’s baseline age expectancy) between 2019 and 2021, whereas red highlights a higher average score on indices or a negative change in life expectancy.
Note: Changes in life expectancy were scaled to each country’s baseline age expectancy to reflect the proportional impact of the pandemic in each setting. The rank of each country was based on data available closest to the pre‑2020 period: EPI (August 2018), GHSI (October 2019), IDVI (September 2016), INFORM (2019), and SPAR (2019). A score of 1 indicates a country was in the highest quintile (lightest blue), reflecting the most preparedness, while a score of 5 represents the lowest quintile (darker blue), or least preparedness. The quintile rank is derived from the entire assessment, including countries not listed in the table as they fall outside the scope of this work. Green denotes an average index score closer to 1 or a positive change in life expectancy between 2019 and 2021, whereas red highlights a higher average score on indices or a negative change in life expectancy.
Source: See Table 6.1 for index sources; OECD (2023[26]), Health at a Glance 2023: OECD Indicators, https://doi.org/10.1787/7a7afb35-en.
While there is no clear relationship between the indices and average life expectancy change, most countries scored well, as shown by the lightest blue shade. Indices generally favour high-income countries, even when their performance does not align with their rankings. INFORM shows the most variation, ranking the 51 countries across all five quintiles, while SPAR covers the top four quintiles. On average, countries scored highest in the INFORM index and lowest in the GHSI, suggesting the GHSI ranked these countries as more likely to perform well during the pandemic. To determine which index best predicted the per cent change in life expectancy across countries during the COVID‑19 pandemic, two analyses were run. Firstly, the correlation between each index score and the per cent change in life expectancy was evaluated. Then, a regression analysis for each index to obtain R-squared values, which indicate the proportion of variance in life expectancy change explained by each index, was also computed. These two results are shown below in Table 6.4.
Note: R-squared values indicate the extent to which changes in life expectancy are explained by each index. A higher R-squared value reflects a stronger ability of the index to predict changes in life expectancy. As such, the R-squared values in this table indicate the proportion of variance in life expectancy change explained by each index, with higher values reflecting stronger predictive power. Correlation coefficients describe the direction and strength of the relationship. Negative values indicate that countries ranked as better prepared (lower index scores) generally experienced smaller declines in life expectancy, while positive values suggest little or no meaningful relationship. EPI = Epidemic Preparedness Index), GHSI = Global Health Security Index, IDVI = Infectious Disease Vulnerability Index, JEE = Joint External Evaluation, SPAR = State Party Self-Assessment Annual Report.
Findings suggest that SPAR and IDVI were the most effective indices for predicting life expectancy outcomes during COVID‑19, while the INFORM showed the weakest predictive power. Countries rated as more prepared by the SPAR and IDVI generally had better life expectancy outcomes, with per cent increases getting as high as 0.5% in certain countries Table 6.3. Note that the SPAR is a self-assessment instrument and as such results may be influenced by national reporting practices, including potential differences in interpretation and the risk of over- or under-reporting preparedness capacities. The SPAR showed the strongest relationship with life expectancy change, with an R-squared value of 0.189 (18.9%) and a correlation coefficient of ‑0.435 Table 6.4. The negative correlation indicates that countries with higher SPAR preparedness (i.e. scores closer to 1) generally experienced less decline or even improvement in life expectancy during COVID‑19. This suggests that the SPAR index was relatively effective in predicting life expectancy impacts, with better-prepared countries (lower scores) seeing smaller declines or better outcomes. The IDVI also showed some predictive power, with an R-squared of 0.088 (8.8%) and a correlation coefficient of ‑0.297. While weaker than SPAR, the IDVI still showed that countries ranked as more prepared (scores closer to 1) tended to have less adverse changes in life expectancy. The INFORM index had the weakest predictive power for life expectancy changes during COVID‑19, with an R-squared value of 0.003 (0.32%) and a correlation coefficient of 0.057, followed by EPI at 0.019 (1.9%) and correlation coefficient of ‑0.137. This indicates that INFORM 2019 explained almost none of the variation in life expectancy, suggesting it did not effectively capture aspects of preparedness relevant to these outcomes.
These results align with emerging evidence. A systematic review of nine studies (2020‑2024) found that higher SPAR scores generally correlated with lower COVID‑19 incidence and mortality, though some high-scoring countries still experienced severe outbreaks (Santalucia et al., 2025[27]). Similarly, regression analysis showed that higher SPAR and GHSI scores were associated with fewer cases and deaths, but only during the first eight weeks after a country’s first case – particularly in smaller countries and those with stronger human resource capacities for pandemic preparedness and response (Duong et al., 2021[28]).
6.3.1. Which aspects of preparedness were most related to performance?
The SPAR and IDVI indices demonstrated stronger correlations with changes in life expectancy during COVID‑19 compared to INFORM and the EPI, largely due to their focus on factors directly relevant to managing infectious disease outbreaks. SPAR captures aspects of countries’ operational readiness – such as public health risk communication, disease detection and reporting, and compliance with international health regulations – which are important for limiting mortality and sustaining health system functionality during a pandemic. Similarly, IDVI reflects broader systemic resilience by incorporating socio‑economic conditions, health system capacity, and governance stability. Although broader in scope than SPAR, these dimensions align with structural factors that influence pandemic outcomes. Together, these characteristics help explain the stronger observed association between SPAR and IDVI and life expectancy changes.
In contrast, INFORM and the EPI showed weaker correlations with life expectancy changes, albeit for varied reasons. While INFORM focusses on general disaster vulnerability and lacks health-specific metrics, the EPI primarily assesses national-level capacities like healthcare infrastructure, financing, and governance, which may not fully capture the operational readiness needed during a pandemic. INFORM’s weaker association may be due to its broader scope and limited emphasis on public health-specific measures. Designed to assess general vulnerability to disasters, INFORM incorporates metrics such as exposure to natural hazards, conflict risk, and socio‑economic inequality, which are less directly tied to pandemic-related outcomes. While INFORM includes vulnerability as a key component, its interpretation of vulnerability is less specific to health system fragility and operational preparedness. Unlike SPAR and IDVI, INFORM does not prioritise indicators related to disease surveillance, risk communication, or healthcare system preparedness – factors that were crucial for reducing mortality and maintaining population health during the pandemic. The EPI focusses on structural aspects of preparedness, such as healthcare systems and resources, but it does not fully consider real-time response capabilities, including rapid disease detection, outbreak tracking, or effective public communication – factors that were especially important during COVID‑19. It also places greater emphasis on pre‑existing capacities and may overlook how well countries adapted to the unique and evolving challenges of the pandemic. As a result, the EPI showed a weaker relationship with changes in life expectancy across countries. This highlights the importance of using indices that balance long-term preparedness with the capacity to respond quickly in a crisis.
Measuring vulnerabilities is crucial for understanding how underlying risks and weaknesses influence a country’s pandemic preparedness and response. The IDVI does this well by looking at factors like income inequality, access to healthcare, and government stability, which all play a big role in how well a country can respond to health crises. These kinds of vulnerabilities help explain why some countries were hit harder by COVID‑19 than others. Conversely, SPAR, INFORM and the EPI do not focus enough on these issues. INFORM looks broadly at disaster risks but doesn’t include specific measures of healthcare access or inequalities that can worsen health outcomes during a pandemic. The EPI, while focussed on epidemic preparedness, mostly evaluates national-level systems like healthcare infrastructure but does not consider how vulnerabilities like poverty or regional differences can make some groups more at risk. SPAR also does not explicitly include themes surrounding vulnerabilities; the only indicator that ascertains any information regarding the topic is in the indicator on community engagement, where a question evaluates if there are any mechanisms for systematic community engagement in public health emergencies. By leaving out these important factors, SPAR, INFORM and EPI do not fully capture the challenges from population vulnerabilities that can affect a country’s performance during a pandemic. This shows how important it is for preparedness measures to include a focus on vulnerabilities to get a clearer picture of risk and resilience. The next section delves into the importance of vulnerability during a pandemic.
6.4.1. What is vulnerability and why does it matter in the context of pandemic preparedness and response?
During the COVID‑19 pandemic, countries with higher social vulnerability faced increased mortality rates. Vulnerable populations are broadly defined as groups of people who face exclusion and discrimination based on factors such as age, disability, race, ethnicity, gender, income level, migratory status, and those who are involved in conflicts or are stateless (Tan et al., 2023[29]). During pandemics, these groups face greater challenges in accessing healthcare facilities and implementing preventive measures like lockdowns, leading to increased vulnerability, higher infection risks, and greater community transmission. Therefore countries, especially those with higher social vulnerability indices, should be particularly concerned about the pandemic’s impact on their most vulnerable populations.
Understanding the indicators of vulnerability can help authorities better manage pandemics in these communities. Identifying and categorising indicators of vulnerability help countries to establish appropriate pandemic prevention and mitigation programmes. Benchmarking regions based on these identified indicators is beneficial for recognising areas that are more vulnerable and have the potential to become pandemic hotspots. Consequently, policymakers can use this information to allocate resources based on needs, such as providing additional vaccines, medical personnel, and medications, to these vulnerable regions during their planning and decision making regarding pandemic planning.
6.4.2. How can we measure the vulnerability of populations to a new pandemic?
Measures of vulnerability against disasters encompass health, economic, social, institutional or deferential, and cognitive or communicative dimensions. Vulnerability arises from individual or group characteristics and conditions, including social inequalities, urbanisation, education, and income levels, which affect their ability to prevent, respond to, and recover from disasters. A 2023 study categorised the types of vulnerability in context of the COVID‑19 pandemic into five categories: health, economic, social, institutional or deferential, and cognitive or communicative vulnerability (Table 6.5) (Tan et al., 2023[29]). These determinants highlight the complex interaction of various factors in a country that influence vulnerability. While there are a variety of indicators to measure vulnerable populations, less visible populations are often overlooked in pandemic preparedness and response plans (see Box 6.4).
Definitions, examples, and indicators used to measure the different types of vulnerabilities in a population
Note: Indicators included in this Table serve as an example of commonly used indicators that could be used to capture the corresponding vulnerability and are not meant to be exhaustive or comprehensive.
Source: Fallah‐Aliabadi et al. (2022[30]), Social vulnerability indicators in pandemics focussing on COVID‑19: A systematic literature review, http://doi.org/10.1111/phn.13075; Tan et al. (2023[29]), Mitigating the impacts of the COVID‑19 pandemic on vulnerable populations: Lessons for improving health and social equity, http://doi.org/10.1016/j.socscimed.2023.116007.
Most countries included visible vulnerable populations in their COVID‑19 responses, but often neglected less visible and hidden populations in formal policy responses. Evidence from the COVID‑19 pandemic suggests that countries prioritised visible vulnerable populations, i.e. measurable populations. This included the elderly population and groups based on health vulnerabilities, such as immunocompromised individuals (those living with asthma or diabetes, for example) and were a key focus in the early phase of COVID‑19 vaccination plans. While health vulnerabilities were prominent during the pandemic, other intersecting vulnerabilities created far-reaching impacts on these populations. For example, less visible and hidden populations, such as migrant workers, refugees, sex workers, prisoners, and people with disabilities, were largely neglected in formal policy responses (Tan et al., 2023[29]).
A country’s ability to account for its vulnerable populations is linked to its capacity to measure them, as well as the situation that the country was in prior to the pandemic. During the COVID‑19 pandemic, some countries were better at accounting for these groups, while others were limited in this capacity. For example, the Centres for Disease Control and Prevention (CDC) in the United States has a comprehensive Pandemic Influenza Plan that includes considerations for vulnerable populations, such as those with underlying health conditions, the elderly, and disadvantaged communities. Additionally, the CDC and Agency for Toxic Substances and Disease Registry (ATSDR) developed the Social Vulnerability Index (SVI) to identify communities that may need support during emergencies. The SVI considers various social factors contributing to vulnerability, including socio‑economic status, minority status, and housing. The SVI uses 16 U.S. census variables to help local officials identify communities that may need support before, during, or after disasters. However, though the United States had the mechanisms in place to measure vulnerable groups, COVID‑19 exposed challenges within the health system in fully meeting the rising caseloads and health needs of those populations, particularly in areas with existing health inequalities.
While “hidden” populations are a heterogeneous group, some may be at greater risk during a pandemic. Migrant workers, for example, were greatly affected by COVID‑19. This is because this group particularly those who earn low wages face higher risks due to precarious working and cramped living conditions. Additionally, restricted access to healthcare due to certain legal and policy restrictions within a country can increase transmission risks and adverse outcomes, as many migrants are excluded from national pandemic plans.
Source: Tan et al. (2023[29]), Mitigating the impacts of the COVID‑19 pandemic on vulnerable populations: Lessons for improving health and social equity, http://doi.org/10.1016/j.socscimed.2023.116007; Molenaar (2022[31]), Vulnerable groups in pandemic times: A cross-country synthesis of pandemic preparedness plans and evaluations of specific COVID‑19 public health responses, http://doi.org/10.13140/RG.2.2.36691.45606; CDC (2024[32]), National Pandemic Strategy, https://www.cdc.gov/pandemic-flu/php/national-strategy/index.html; ATSDR and CDC (ATSDR and CDC, 2024[33]), CDC/ATSDR Social Vulnerability Index (CDC/ATSDR SVI): Overview, https://www.atsdr.cdc.gov/placeandhealth/svi/index.html.
Rankings and indices are supposed to show how well a country can handle a pandemic, but COVID‑19 revealed that they were not accurate (Stoto, Nelson and Kraemer, 2023[34]). At the country level, health outcomes during the first wave of COVID‑19 were primarily negatively correlated with the expected preparedness rank in the indices, such as those in Table 6.1. For instance, a country’s rank on indices such as the INFORM and GHSI did not necessarily reflect how well country responded to and were affected by the pandemic.1 The reasons for which the indices have not effectively predicted COVID‑19 preparedness for many countries include:
Indices are biased in favour of countries with more resources and certain characteristics: Indices generalise the situation across countries and overlook the diverse demographics, cultures, and political landscapes within them (Kachali et al., 2022[5]). Many indices lack contextualised or country-specific factors, such as political trust (Grabar-Kitarović and Phumaphi, 2023[14]). For instance, during the COVID‑19 pandemic, countries ranked at the top were often similar in terms of development levels, primarily coming from high-income nations, which is clear also in Table 6.3. This high ranking could be attributed to a bias favouring countries with more advanced reporting systems, which are more prevalent in high-income countries, and only partially predict the ability of a country to respond to crises. It is important to point out that the inverse is not necessarily true; it is not that countries with lesser levels of income necessarily performed better during the pandemic. Instead, it highlights that the indices, in their current format, favoured attributes often present in health systems of countries with higher levels of income. Even the GHSI, which previous studies have deemed as a comprehensive evaluation with 140 items, has faced doubts about its validity and reliability. These concerns raise the possibility of miscalculations and misinterpretations (Kachali et al., 2022[5]).
Their lack of contextualisation and inability to account for dynamic response capabilities: Many indices generalise conditions across countries, ignoring differences in demographics, cultures, political systems, and key factors such as political trust. Socio‑economic issues, including inequality, public compliance with health measures, and population structure, are often inadequately captured. Furthermore, physical characteristics, such as whether a country is an island, its size, and its population density, significantly affect response to an emerging pandemic but are rarely incorporated into these evaluations. The ability of a country to adapt and respond to a pandemic as it unfolds is crucial but often overlooked. Dynamic response capability is a key determinant of pandemic preparedness and response since pandemics are inherently unpredictable. They require constant adjustments in strategy, resources, and public health measures. As such, preparedness is not just about having strong systems in place but also about being able to react to new threats, update plans with fresh evidence, and act quickly. Indices that overlook this dynamicity risk miscalculating the strength of systems to innovate and adapt, like increasing testing capabilities or developing new treatments. As a result, indices fail to reflect the nuanced factors that determine a country’s actual ability to manage pandemics.
Existing indices are likely founded on lessons learned from past pandemics: The novel COVID‑19 pandemic was exacerbated by factors such as the novel nature of the virus, asymptomatic transmission, and increased spread facilitated by globalisation. While previous indices have been developed based on lessons learned from past epidemics, these events often differed in terms of their severity, transmission dynamics, and impact (Bollyky et al., 2022[35]). For instance, some epidemics like severe acute respiratory syndrome (SARS) were successfully contained, while others like the 2009 H1N1 influenza had lower mortality rates. Additionally, the pace of transmission varied, with diseases like human immunodeficiency virus (HIV) spreading more slowly (Kachali et al., 2022[5]). Existing preparedness indices are not adequately updated to address the unique challenges of modern societies, particularly in the context of extensive air travel (Jeanne et al., 2023[8]). This lack of adaptation has contributed to disparities between rankings in indices and actual performance during the COVID‑19 pandemic (Kachali et al., 2022[5]).
Data constraints affected reporting: While the IHR requires WHO member countries to establish preparedness plans for public health crises and regularly assess and update them, not all member countries fully adhere for a breadth of reasons. Some countries face constraints in implementing recommendations due to limited resources or are hesitant to adapt systems following WHO’s outbreak notifications due to potential economic losses (Kachali et al., 2022[5]). Additionally, some countries experienced challenges such as missing data or reporting lags, which may lead to an incomplete or inaccurate understanding of the situation, potentially overlooking crucial dimensions necessary for an effective response. Furthermore, retrospective data corrections and rapid changes to case definitions may occur, posing difficulties that cannot be easily addressed by data compilers but could have contributed to inaccuracies in the indices (Badker et al., 2021[36]).
Indices measure only what can be observed, leaving out political and governance issues: Indices prioritise structural and measurable aspects of the health system, such as capacity, laboratory infrastructure, financing, surveillance, and emergency response operations. While these factors are important to measure, indices often lack robustness in assessing qualitative aspects that are hard to quantify but essential in pandemic preparedness and response. The COVID‑19 pandemic highlighted the critical role that these governance‑related measures (including trust, (mis)information, co‑operation, and collaboration, but also response capacities, societal and community involvement, and whole‑of-government co‑ordination) play in effectively managing such crises; these attributes have influenced countries’ capacity to prepare proactively, respond promptly, and achieve equitable recovery while safeguarding community public health. Neglecting these factors has contributed to the skewing of existing indices in favour of high-income countries. For more information on issues related to governance, please refer to the OECD Framework on drivers of public trust and the OECD’s 2023 Trust Survey (OECD, 2024[37]; Brezzi et al., 2021[38]). Further, this has underestimated the significance of leadership and societal involvement in translating policy planning into action (Tan et al., 2021[39]).
Index questions do not accurately capture the ability of a country to scale up response and production of supplies: Traditional indicators are based on data availability that may not adequately predict a country’s preparedness for pandemics like COVID‑19. While many indices include various health system and capacity indicators such as healthcare personnel, medical equipment, and access to care, COVID‑19 demonstrated the limitations of relying solely on these measures (Kentikelenis and Seabrooke, 2021[6]). COVID‑19 overwhelmed healthcare systems in certain regions, leading to challenges in managing both COVID‑19 and non-COVID‑19 patients, which contributed to additional mortality. This highlights the importance of incorporating the ability to scale up the supply of resources into existing preparedness indices, which was not commonly included in indexes. Another example of this overlooked factor was the capability to ramp up production of masks and personal protective equipment (PPE), crucial components in the COVID‑19 response, yet deficient in some countries (Kachali et al., 2022[5]).
Although standard preparedness indices failed to predict COVID‑19 outcomes, it does not mean that they should be dismissed. Even if the theoretical level of a country preparedness did not correspond to the facts, and do not prevent countries from experiencing severe COVID‑19‑related consequences, this should not be a reason not to use indices as a guide. Instead, the experience with COVID‑19 should prompt discussions on how to better understand and improve our capacity to measure preparedness for future pandemic responses. For instance, the COVID‑19 pandemic underscored significant disparities in countries’ preparedness infrastructures, directing attention to areas needing improvement. This underscores the importance of further investigating the development and enhancement of preparedness indices (Kachali et al., 2022[5]). Some suggestions for improving how indices are utilised and/or the data collected are discussed in the next section.
6.5.1. How can existing indices be strengthened for future pandemics?
During COVID‑19, preparedness rankings failed to reliably predict countries’ performance, exposing flaws in global pandemic response systems. Post-COVID‑19 pandemic, it is crucial to reassess how preparedness is measured (Legido-Quigley et al., 2023[40]). Below are some frequently overlooked traits that could enhance future pandemic indices:
Take account fixed characteristics of countries: Fixed-country characteristics such as greater geographic connectivity (i.e. the degree to which different locations or regions are connected to each other through various means of transportation, communication, or other networks), population age, income level, or limited experience in handling pandemics can elevate a country’s risk level and therefore should be taken into account (Rose et al., 2021[41]). Ignoring these factors can bias our understanding of preparedness, as seen during COVID‑19, where rankings often favoured high-income countries, raising questions about the adaptability and relevance of such frameworks in diverse contexts (Legido-Quigley et al., 2023[40])
Include a range of population vulnerabilities: COVID‑19 has been a pandemic of inequality, hitting marginalised and disadvantaged people the hardest; inequality has played a big role in explaining why the pandemic affected people’s lives and jobs so differently (Sirleaf and Clark, 2021[42]). As highlighted earlier in this chapter, including a wide range of vulnerability indicators – such as health, economic, social, institutional, and cognitive factors – can help policymakers identify and compare areas at greater risk. This allows them to allocate resources more effectively and create customised plans to prevent and manage pandemics. Targeted actions, like prioritising vaccine distribution, sending medical teams, and ensuring necessary supplies, can reduce inequalities and strengthen resilience against future pandemics.
Include sociopolitical and governance variables: These factors, like social polarisation, political trust, social cohesion, and perceptions of corruption, have a big effect on extra deaths during the COVID‑19 crisis. Many indices overlook important qualitative factors such as leadership, community engagement, at the national, regional, and international level. For example, during COVID‑19, some leaders failed to take responsibility or create clear strategies to stop the spread of the virus, which was made worse by ignoring scientific evidence (Sirleaf and Clark, 2021[42]). Failing to adequately address intangible elements like building trust within societies or confidence in political leaders, which are challenging to measure and quantify, is essential (Legido-Quigley et al., 2023[40]). During COVID‑19, strong political leadership was crucial to enforce pandemic protocols and build trust in the government’s response. Additionally, the levels of trust among people and in government institutions are essential because public health capacity alone is not enough if not effectively utilised (Rose et al., 2021[41]). The concept of trust in the context of a pandemic will be explored more in other chapters.
Include international collaboration in future indices: Enhancing preparedness indices requires countries to collaborate more effectively, sharing resources and information to expedite decision making. Strengthening international collaboration entails improving the capacity to provide necessary services and supplies promptly, as well as reacting swiftly to circumstances such as implementing social distancing measures. While international co‑operation is underscored in indices like the IHR and GHSI, challenges emerged during the initial phases of the COVID‑19 response due to disagreements among experts and conflicting country interests. These aspects were not adequately factored into assessments of pandemic preparedness and response (Kachali et al., 2022[5]).
Adopt a One Health approach: Most of the indices reviewed in this chapter include biological or environmental hazards as part of their assessment frameworks, but few fully capture the interconnected drivers of disease emergence. Population growth, land-use change, food production practices, and environmental degradation are accelerating the spread of new pathogens – most of which originate in animals and are amplified by human activity and global mobility. To address these risks, future preparedness assessments should adopt a comprehensive One Health perspective that that engages human, animal, and environmental health sectors to assess risk, support co‑ordinated action, and respond effectively to emerging or re‑emerging infectious diseases. This includes integrating animal health surveillance, environmental monitoring, and human-wildlife interface indicators, as well as strengthening co‑ordination across relevant programme areas and domestic environmental agencies with the necessary technical expertise. Incorporating these dimensions would help identify emerging threats early and prevent spillover events. Effective pandemic planning therefore requires sustained cross-sectoral collaboration to operationalise the One Health approach (Sirleaf and Clark, 2021[42]).
Include capacity to mobilise rapidly: Countries with poor pandemic preparedness and response often lacked the capacity to quickly mobilise resources and co‑ordinate effectively between national and local level. This can result in inconsistent implementation of critical measures like testing, contact tracing, and vaccine distribution, while also straining healthcare systems and fostering public mistrust. Measuring and strengthening a country’s capacity to quickly mobilise is essential to ensure a timely and co‑ordinated response to fast-moving health threats, preventing unnecessary escalation and loss of life (Sirleaf and Clark, 2021[42]).
Pandemic preparedness and response are a critical public health function, but COVID‑19 has revealed major gaps in how preparedness was assessed. While indices are designed to identify weaknesses, they often fail to address the full complexity of preparedness, particularly social vulnerabilities, and a country’s ability to adapt and scale‑up during health crises. As such, this chapter reviews six pandemic preparedness and response indices, highlighting their strengths and limitations. SPAR and IDVI showed stronger correlations with changes in life expectancy during COVID‑19, while INFORM and EPI were less strongly associated. However, all indices shared common shortcomings: they often favoured wealthier countries, overlooked critical factors like governance and trust in institutions, and failed to account for public health communication and response capabilities or scalability.
Despite these issues, preparedness indices remain valuable tools for evaluating preparedness. To improve their effectiveness, future indices should incorporate fixed country characteristics, social vulnerabilities, and political and governance factors. They should also include biological and environmental risks to reflect the realities of emerging health threats. By aligning preparedness measurements more closely with operational capacities, these tools can better support countries in building resilience to future pandemics.
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The GHSI, developed by the Nuclear Threat Initiative (NTI), Johns Hopkins Centre for Health Security, and the Economist Intelligence Unit (EIU), served as the first comprehensive health security capacity assessment of the member countries subscribed to the 2005 IHR. The GHSI is a benchmarking index, that serves as an objective tool for assessing countries on a national level annually. The GHSI employs a comprehensive multidimensional framework, comprising six categories: 1) Prevention of pathogen emergence or release; 2) Early detection and reporting of potential international epidemics; 3) Rapid response and epidemic spread mitigation; 4) Adequate health system infrastructure to treat the sick and protect health workers; 5) Commitments to enhancing national capacity, financing plans, and adherence to global norms; and 6) Overall risk environment and country vulnerability to biological threats. These categories encompass specific indicators and sub-indicators, measured using publicly available data and validated by external experts. Indicators include factors such as healthcare access, epidemiology workforce, disease surveillance systems, laboratory capacity, emergency response protocols, and compliance with international health regulations.
Source: Economist Impact (2021[43]) GHS Index Methodology, https://ghsindex.org/.
Within these indicators are sub-indicators, with each sub-indicator incorporating data from multiple questions. For instance, “healthcare access” includes three sub-indicators: access to healthcare, paid medical leave, and healthcare worker access to healthcare. Each question (171 in total) receives a score based on predefined criteria. For example, for the question on guaranteed paid sick leave, a country that has paid sick leave would score a value of 2, whereas a country with unpaid sick leave would be assigned a value of 1, and a country without any would score a value of 0 for that question. These individual scores feed into sub-indicators (96), which then contribute to indicators (27), categories (6), and ultimately the final scores.
The GHSI assigns overall scores between 0 and 100 to each country, with higher scores indicating better preparedness in health security. This scoring system enables thorough assessments of strengths and weaknesses, aiding countries in identifying areas for enhancement and guiding investments in health security. Additionally, the GHSI offers flexibility by allowing adjustments to the weights assigned to each category and indicator within its data model. This feature enables the interpretation and application of the index’s findings according to varying assumptions about their relative importance.
The first step of the JEE process involves a self-assessment carried out by the country with multisectoral involvement, utilising the JEE tool and country implementation guide. This self-evaluation covers four categories, including: 1) Prevent; 2) Detect; 3) Respond and 4) International Health Regulation (IHR) – related hazards and points of entry and border health. These four categories encapsulate 19 capacities outlined in the tool, which cover a variety of topics, including linking public health and severity authorities, surveillance, human resources, health services provision, and health emergency management. Within each of the 19 capacities, there exists a varying number of indicators. For instance, there are three indicators in the “surveillance” category, and each of the indicators measures different aspects of a country’s public health surveillance capacities. Table 6.3 presents one of the indicators within the surveillance category, namely the indicator “Early warning surveillance function.” This indicator assesses the functionality of the country’s public health surveillance system and its ability to identify potential events of concern for public health and health security. In the JEE tool, each indicator is evaluated using a scoring system ranging from “1” (indicating no implementation) to “5” (indicating full implementation, including testing, review, and exercise, with sustainable capability). A single score is assigned to each indicator based on consensus regarding the country’s current implementation, facilitated by “technical area questions” to guide evaluators.
Note: This indicator is measured for priority epidemic prone diseases conducted according to international standards. In this indicator, surveillance is defined in the report as the systematic ongoing collection, collation and analysis of data for public health purposes and the timely dissemination of public health information for assessment and public health response, as necessary.
Source: World Health Organization (2022[17]), Joint external evaluation tool: International Health Regulations (2005), third edition, https://www.who.int/publications/i/item/9789240051.
Following the self-evaluation, an external JEE team comprising of international subject matter experts conducts on-site visits to review data and hold meetings organised by the host country. These assessments involve descriptive and qualitative analysis, with countries expected to provide supporting documentation. Evaluators engage in peer-to-peer discussions with host country experts to reach a consensus. The final report includes scores, a narrative on existing capacities, identified gaps, challenges, and recommendations. Key findings are condensed into three to five priority actions for each of the 19 technical areas.
← 1. Studies often use simple measures like total cases and deaths at a fixed point in time to assess a country’s pandemic response; however, this approach overlooks the multifaceted definition of success, including different health outcomes, types of interventions, and timing, as well as economic and social disruptions. Therefore, early success may not reflect later stages, especially with the introduction of vaccines. Also, total cases and deaths do not show differences within countries, like socio‑economic or geographic disparities. (Stoto, Nelson and Kraemer, 2023[34]).