Background
The COVID-19 pandemic brought attention back to the International Health Regulations 2005 (IHR). IHR (2005) is an instrument of international law for the World Health Organization (WHO) Member States, adopted in May 2005 and entered into force in June 2007 in response to the emergence of global outbreaks [
1]. The primary purpose of the IHR (2005) is
"to prevent, protect against, control, and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks and which avoid unnecessary interference with international traffic and trade" [
1]. To achieve the primary goal of protecting countries against the international spread of diseases, the IHR requires all 196 countries that ratified the regulations to maintain and develop eight capacities [
2]. These public health capacities include (1) national legislation, policy, and financing; (2) coordination and national focal point communications; (3) surveillance; (4) response; (5) preparedness; (6) risk communication; (7) human resource capacity; and (8) laboratory. The IHR called for States Parties to maintain five additional core capabilities to establish the capacities at Points of Entry (PoE) and respond to zoonotic, food safety, and chemical events in addition to radiation emergencies [
2]. WHO had set up components and indicators for each capacity and capability for State Parties to facilitate the monitoring and evaluation of their capacities' maintenance and identify implementation gaps (see Table
1) [
3].
Table 1
IHR capacities and indicators
C1: Legislation and Financing | C.1.1 Legislation, laws, regulations, policy, administrative requirements or other government instruments to implement the IHR |
C.1.2 Financing for the implementation of IHR capacities |
C.1.3 Financing mechanism and funds for timely response to public health emergencies |
C2: IHR Coordination and National IHR Focal Point Functions | C.2.1 National IHR Focal Point functions under IHR |
C.2.2 Multisectoral IHR coordination mechanisms |
C3: Zoonotic Events and the Human–animal Interface | C.3.1 Collaborative effort on activities to address zoonosis |
C4: Food Safety | C.4.1 Multisectoral collaboration mechanism for food safety events |
C5: Laboratory | C.5.1 Specimen referral and transport system |
C.5.2 Implementation of a laboratory biosafety and biosecurity regime |
C.5.3 Access to laboratory testing capacity for priority diseases |
C6: Surveillance | C.6.1 Early warning function: indicator-and event-based surveillance |
C.6.2 Mechanism for event management (verification, risk assessment, analysis investigation) |
C.7 Human Resources | C.7.1 Human resources for the implementation of IHR capacities |
C.8 National Health Emergency Framework | C.8.1 Planning for emergency preparedness and response mechanism |
C.8.2 Management of health emergency response operations |
C.8.3 Emergency resource mobilization |
C.9 Health Service Provision | C.9.1 Case management capacity for IHR relevant hazards |
C.9.2 Capacity for infection prevention and control and chemical and radiation decontamination |
C.9.3 Access to essential health services |
C.10 Risk Communication | C.10.1 Capacity for emergency risk communications |
C.11 Points of Entry | C.11.1 Core capacity requirements at all times for designated airports, ports and ground crossings |
C.11.2 Effective public health response at points of entry |
C.12 Chemical Events | C.12.1 Resources for detection and alert |
C.13 Radiation Emergencies | C.13.1 Capacity and resources |
Under Article 54 of the IHR (2005), each State Party has to report the status of capacities' implementation annually by employing the IHR State Party Self-Assessment Annual Report (SPAR) [
3,
4]. Annually, all State Parties should assess their capacities and submit the results to WHO using the SPAR tool, imposing the potential to be influenced by biases [
5]. To enhance the transparency and accountability of the States Parties, the Joint External Evaluation (JEE) tool was introduced in 2015 to identify progress, ensure sustainability, find areas of strengths and weaknesses, and recommend suggestions for improving national health [
6]. The scoring of SPAR and JEE tools is based on a scale scoring system. A cross-sectional study that observed the association between SPAR capacities’ scores and COVID-19 outcomes across 114 countries revealed that countries with higher IHR scores were significantly more likely to have better COVID-19 outcomes, such as a reduction in the rate of mortality and morbidity [
4].
Lebanon and the international health regulations
Lebanon, a small country of 10,452 km
2, ratified the IHR (2005) in 2007 [
7]. The country witnessed economic prosperity from the 1950s until 1975, when a devastating civil war undeniably affected the economic sector, escalating public debt and budget deficits [
8]. After the end of the civil war (1975–1989), the health sector was again exposed to two Israeli ferocious aggressions: the Grapes of Wrath operation in 1996 and the 2006 war [
9]. As a result of protracted instabilities, the Lebanese health system has been highly fragmented throughout history, with a strong involvement of the private sector and a widespread use of out-of-pocket payments [
8]. Lebanon has been unhinged by neighboring countries' crises. Since the Israeli occupation of Palestine, the country’s rugged mountains and cities have given refuge to more than 479,000 Palestinian refugees [
8]. The eruption of the Syrian crisis in 2011 has caused an estimated 1.5 million refugees to seek sanctuary in Lebanon [
10]. The Lebanese health system has been challenged to respond to this humanitarian crisis, with a 30% increase in the population, that worsened the fragmentation and privatization of the health system [
10,
11]. Eighty-five percent of the registered refugees live in 182 localities, where 67% of the host community lives below the poverty line [
10].
Over 500,000 unregistered Syrian refugees live in informal settlements (ITSs) with poor sanitary and environmental conditions and barriers to acquiring healthcare services due to high cost and lack of accessibility [
12,
13]. These poor hygiene conditions have led to outbreaks of waterborne diseases such as diarrheal diseases and hepatitis A (HAV) [
14,
15]. Multiple eradicated diseases were re-introduced in Lebanon as a result of the Syrian crisis. For example, the disruption of immunization activities in Syria re-introduced measles in 2013 [
16] and mumps in 2015, mainly located in the North and the Bekaa, where the highest number of Syrian refugees lived [
17]. The number of tuberculosis (TB) cases has also increased in Lebanon due to treatment interruption accompanying the worsening security situation inside Syria [
18]. Despite the outbreak of poliomyelitis in Syria, the leadership of the Ministry of Public Health (MOPH) succeeded in keeping Lebanon polio-free [
19].
On February 21, 2020, COVID-19 hit Lebanon [
20], accompanied by a severe financial crisis. Not only has Lebanon been affected by political deadlocks, financial deterioration, and infectious disease emergencies, but it has also been devastated by the third most catastrophic chemical explosion of all time after the Hiroshima and Nagasaki nuclear explosions [
21]. The Beirut port explosion resulted in 600 causalities, 180 deaths, 24,600 affected migrants [
22], and US$15 billion in economic losses [
23]. It was reported that the blast resulted from a 2.75-kilo ton of NitroprilTM stored inappropriately due to political negligence [
24]. In addition to the direct health implications, the Beirut blast released toxic gases that threatened Beirut's residents [
24]. The blast implications highlighted the gap in chemical safety measures in Lebanon and the absence of appropriate preparedness and proper emergency response for chemical-related emergencies. This is ample evidence of Lebanon's vulnerability to emergencies of all types: infectious disease outbreaks, environmental changes, chemical hazards, and financial and political emergencies amplified by neighboring countries' crises.
The assessment of Lebanon's IHR capacities was done in 2016 using the JEE tool [
25]. However, there have been no independent studies that expand our understanding of the Lebanese capacities to prevent, detect, and respond to public health events, especially after COVID-19 which revealed many gaps in the health system. This paper aims to gain a better understanding of (1) the IHR capacities’ scores of Lebanon in comparison to other countries; (2) the IHR milestones and activities in Lebanon; (3) the challenges of maintaining the IHR capacities; (4) the refugee crisis's impact on the development of these capacities; and (5) the possible recommendations to support the IHR performance in Lebanon.
Discussion
This is the first study to provide mixed-method findings on the status of IHR capacities in Lebanon. It delivered results of high importance, especially after the emergence of COVID-19. Lebanon was one of the 65 (33%) State Parties that met the minimum core capacity standards in the meeting of the IHR Review Committee in November 2014, while the other 81 States Parties had requested a two-year extension and 48 had not communicated their intentions to the WHO [
50]. Despite this high level of commitment to meeting the IHR capacities, our findings demonstrated several gaps in the IHR performance due to the perpetual challenges Lebanon has been facing on the economic, political, and social levels [
51].
This study introduced a new approach to understanding Lebanon's IHR capacities by analyzing e-SPAR scores and complementing them with an in-depth knowledge of IHR experts. We only analyzed the 2020 capacities' scores as a result of multiple revisions in the e-SPAR tool, which made it impossible to study the trend of scores over time [
3]. We categorized the scores into five health security indices: prevent, detect, respond, enabling function, and operational readiness, based on a study done by the WHO Health Emergency Program in Geneva [
4]. Lebanon had levels of 4 (≤ 80%) on the five indices. The country scored more than its neighboring countries, Syria and Jordan, which have similar contexts of economic crises, emergencies, and refugee waves. These scores indicate that the country has adequate resources and national plans to prevent, detect, and respond to any future emergencies. This contradicts the qualitative findings, thus posing a concern about those indices' ability to capture the actual performance of the IHR capacities. This contradiction may arise from the fact that all indicators are given the same weight. For instance, in the prevention capacity, more work should be done on the entry points, zoonotic, and food safety indicators, where the country scored less than other indicators in the prevention area. Additionally, to enhance its detection capacities, Lebanon has to work more on the laboratory specimen referral and transport system indicator, in which it scored less than the other indicators. Although Lebanon exceeded its neighboring countries' scores in terms of enabling function and operational readiness to respond to future public health emergencies, it is still not making efforts in many indicators, such as human resources capacities and multisectoral collaboration under the IHR.
Our paper investigated the milestones that Lebanon has executed since it ratified the IHR in 2007. Although we cannot capture all milestones due to data limitations, it was evident that the country has been advancing its capacities (Fig.
3). Despite all the efforts that the country has made to strengthen its IHR capacities, challenges still exist, as reported by the key informants. For instance, many gaps exist in the legislation area, most notably the failure to pass the framework law for IHR implementation that aims to recognize the IHR framework as domestic law and incorporate it within the concerned ministries and entities, as many countries did: France, Finland, Syria, Sweden, and Australia [
52]. This absence of an accountability framework may be attributed to bureaucratic hurdles and vested interests, the main characteristics of governance in Lebanon, leading to miscoordination mechanisms and a lack of commitment among some concerned entities. According to the IHR Review Committee on COVID-19, effective IHR implementation requires political commitment nationally and internationally [
53].
Lebanon has made some progress in its coordination capacity; however, the multisectoral IHR coordination mechanisms are still not fully functional. A definition of multisectoral collaboration should be revisited to identify the key entities and their responsibilities. Multisectoral coordination was emphasized in a study conducted on IHR in Yemen, which recommended improving the alignment of international non-governmental organizations programs with government health programs and aligning both towards better implementation of the IHR [
54].
This study also shows that the country has been working hard on the national emergency framework by strengthening the EWARS [
35], through developing operating procedures, contingency plans, and surveillance guidelines for many diseases, including zoonotic ones, in addition to conducting simulation exercises and training. However, the shortage of human resources is impeding such efforts. This is inevitable in a country like Lebanon, as the World Bank warned that “brain drain” or the alarming migration of qualified people is an “increasingly desperate option” as a result of one of the most severe crises in the world [
55]. The Lebanese crisis has not only affected the human resources area but also impacted the surveillance capacity, a critical pillar in IHR and an area where the country has been making much effort to strengthen and produce one strong epidemiological surveillance program. The negative impact of the Lebanese crisis was emphasized by key informants who reported that the deficit in the infrastructure of electricity and the Internet is impacting the daily routine of indicators and event-based surveillance systems. For Lebanon to have a robust and resilient surveillance system that can detect all public health risks, infrastructure, and resources should be in place. The laboratory is another essential area that Lebanon was doing fair in strengthening it. One impressive strength here is Lebanon's commitment to the WHO recommendation of pooling international laboratory resources through collaborating centers at the local, national, regional, and international levels [
3]. However, the main challenge in the case of Lebanon is the absence of a central laboratory [
25], while its neighboring country Jordan possesses such a laboratory [
56].
The qualitative findings in our study revealed that RCCE measures are being implemented on an ad hoc basis in Lebanon. More investment in RCCE measures is necessary while ensuring the inclusion of vulnerable populations such as Syrian, Palestinian, and Iraqi refugees and migrant workers, who experience marginalization amidst the absence of equitable social protection schemes [
57].
Lebanon, as stated by the IHR, embraced an “all-hazard” strategy. For this, it acknowledged zoonotic diseases, radio-nuclear, and chemical emergencies as actual emergencies. This was evident in the foundation of the CBRN national team in 2013 and the HazMat teams in 2017 [
25,
34]. This does not diminish the need to strengthen the financial and human resources to detect and respond to chemical and radiation emergencies, especially after the Beirut blast implications that highlighted the gap in chemical safety measures in Lebanon and the absence of appropriate preparedness and proper emergency response for chemical-related emergencies [
24]. This was also highlighted in the JEE report, which emphasized the need for a national strategic plan for chemicals, reflecting the needed workforce and financial resources [
25]. At the human-animal interface, Lebanon was able to prepare contingency plans for many zoonotic diseases, such as avian influenza. However, the shortage of kits, materials, and staff at some localities is hampering the ability to conduct ongoing investigations. Other suspected hazards are foodborne diseases. The reported gap here is the overlapping mandates between different entities, with the involvement of the Ministries of Health, Industry, Economy, Trade, Agriculture, and producers and consumers, causing a conflict of power [
25].
The former gap in coordination is also present at the PoE in Lebanon. The 2021 PoE assessment highlighted the deficiency in the required equipment and procedures under IHR at the ground crossings and ports in Lebanon due to the absence of the non-health authorities' commitment. This challenge was asserted in this qualitative study, highlighting the need to have more involvement and commitment from the non-health authorities, such as Customs and General Security. The Lebanese political context of pluralism and mismanagement hinders any progress, especially with the importance of entry points in trade and economic profits, placing it as an area of corruption.
To our knowledge, no study before has investigated the impact that refugees impose on IHR (2005) capacities in a country. Key informants reported that the refugee crisis increased the prevalence of infectious diseases. This was evident between 2013 and 2019 for HAV, CL, mumps, and measles [
58]. One interesting finding in our paper is the positive impact that refugees had on IHR performance according to some key informants; however, this could not be coupled with quantitative evidence from the e-SPAR tool. The refugee influx required Lebanon to establish coordination mechanisms between many entities, including ministries, the private sector, NGOs, and UN agencies. These mechanisms were used and strengthen the coordination mechanisms in the area of IHR. Whether refugees interfere with IHR development is still an area that needs further investigation. However, it is clear that the IHR capacities and its monitoring tools, such as e-SPAR and JEE, have not addressed whether refugees, displaced persons, and migrants should be integrated into the national health prevention, detection, and response approach in addition to the need to support the countries that host refugees.
To our knowledge, this is the first study to explore the performance of IHR in the context of Lebanon since 2016, when JEE was conducted. Another strength of our paper is that it uses a mixed-method design to expand the understanding of IHR status in Lebanon. Moreover, we interviewed key informants from different entities and institutions. Our paper also has some limitations. The e-SPAR tool was revised multiple times since its establishment, which hampered the ability to do detailed quantitative analysis of trends over time. Another limitation is that the number of interviews was relatively few (n = 9) because of the difficulty of reaching IHR experts due to their busy schedules. Interviewing healthcare professionals, field workers or patients would have also enriched the paper.
Implications for policy and research
Many policy and research implications have arisen from the desk-based review and qualitative analysis of this study. We believe that Lebanon’s experience in implementing IHR (2005) capacities is unique and useful for countries facing the same norms of new and emerging political, social, and economic crises.
Reconsidering the weight given to IHR (2005) capacities when assessing them
Despite the significant challenges Lebanon is facing, the findings of this study highlighted that Lebanon is doing relatively well in preventing, detecting, and responding to public health emergencies. This poses a concern about whether all the capacities should be given the same weight when assessing them. The Delphi technique could be used with IHR National Focal Points to prioritize the most critical indicators [
59].
With the compounded crises Lebanon has been assailed by, good governance is a prerequisite to strengthen IHR compliance. The main principle of promoting governance is establishing an accountability framework to ensure participation and transparency with open information systems [
60]. Despite the current political instability in the country, adopting the law is detrimental to establishing an accountability framework for all the concerned parties. This could be done by developing advocacy plans to mobilize political commitment, taking advantage of windows of opportunities such as the COVID-19 pandemic that had an enormous impact on the country's social, economic, and political spheres. Without good governance, multisectoral collaboration cannot be effectively achieved.
Strengthening multisectoral coordination mechanisms
While solid participation by the health and agriculture sector is common in Lebanon, it is not solid in the non-health sector. Nowadays, the increasing public health risks, such as biological, chemical, and radio-nuclear, highlight the responsibility of the non-health sectors in public health risk prevention and control. Cross-sectoral collaboration is essential, and the sectors include but are not restricted to, animal and human health, chemical and radiation safety, the Army, Defense, the Internal Security Forces, General and State Security, the Customs administration, finance, transport, foreign affairs, and the Media. Establishing communication channels as electronic platforms is crucial to facilitating the efficient and timely transmission of information [
61]. These channels would ensure constant communication instead of the existing ad-hoc networks. Moreover, partnerships with civil society organizations (CSO) and dedicating significant effort to raising awareness among them about IHR (2005) could also serve as an advocacy approach to ensure political commitment, especially with their success stories in influencing the policy-making process in the country [
62]. CSOs in Lebanon are known for their role in monitoring the government and holding stakeholders to account. Additionally, technical cooperation with international organizations, especially those providing services to refugees and displaced persons, should be enhanced to avoid duplication of resources and efforts.
Reinforcing risk communication strategies constantly
This study showed the gap in risk communication strategies in Lebanon that is being done on an ad-hoc basis. The findings of this study established the need to conduct constant RCCE strategies, not only during public health emergencies.
Mobilizing and advancing the capacities of human resources at the central and sub-national levels
After the recent economic crisis, Lebanon started suffering a dangerous depletion of human capital. Therefore, it is essential to begin by identifying gaps in the workforce in terms of localities and competency to ensure that training and resources are targeting the needs [
61]. Constant training and simulation exercises are required, especially with the high staff turnover.
Ensuring sustainable financing
In Lebanon, IHR development relies on WHO and funds allocated by MOPH to establish health units at the PoEs. Due to the economic crisis, the currency devaluation, and the competing priorities, there is a huge need to allocate sustainable funding for IHR development. This could be done in partnership between the government, international organizations, and non-State actors [
61]. Article 44 of IHR (2005) affirmed that States Parties should collaborate to mobilize financial resources [
1]. Therefore, increasing WHO Member States' contributions to countries facing emerging challenges is a logical funding resource.
Integrating refugees and displaced persons in the IHR (2005) framework and its assessment tools
The desk-based review revealed that the IHR framework and its assessment tools, such as JEE and e-SPAR, did not address how refugees and displaced populations are integrated into the country's prevention, detection, and response approach to public health emergencies. WHO leadership should take a fresh look at IHR implementation in countries with large displaced populations to discuss with its partners, such as the United Nations High Commissioner for Refugees (UNHCR) and the International Organization for Migration (IOM), the method of integrating special populations within the framework. This could be done by updating the capacities' indicators to involve displaced populations and providing specific recommendations to States Parties hosting these populations. Moreover, mobilizing financial resources for host countries should be considered.
Acknowledging risk mapping as a pre-requisite to a successful response
Benjamin Franklin stated in the eighteenth century, "By failing to prepare, you are preparing to fail" [
63]. Risk mapping is an essential component of any early-warning system. This study highlighted the importance of risk mapping amid the instabilities of Lebanon. This could be done by brainstorming suspected risks.
Trengthening research on IHR (2005) implementation in Lebanon
There is a need for academia in Lebanon to invest their efforts in spotting light on IHR. Producing evidence-based research on IHR would serve as an advocacy approach to strengthen political commitment. Moreover, it is essential to produce policy briefs on the importance of the IHR framework in preventing, detecting, and responding to public health emergencies and distributing them to policy-makers. There is a need to conduct research-based studies on each of the 13 capacities implementation in the Lebanese context.
Conclusion
Lebanon's unique political context has consequences on IHR governance. The alarming level of migration among human resources working with IHR as a result of the current economic crisis is leading to resource depletion that may hamper Lebanon's ability to prevent, detect, and respond to future health emergencies. This magnifies the need for States Parties' support to mobilize financial resources to the IHR pool fund to countries facing similar challenges as Lebanon.
Our study is the first to identify the impact of refugees on the IHR capacities in a country. Although we could not address the effect of refugees' presence on capacities’ scores over the years due to data gaps, the study highlighted that there is a need for WHO and its Member States to mobilize more financial and human resources to support countries hosting displaced populations in maintaining their IHR capacities. The study also highlighted the need to acknowledge the role of refugees in establishing coordination mechanisms between governmental authorities and non-governmental and international organizations, which is advantageous for IHR coordination mechanisms.
The COVID-19 pandemic was a litmus test for Lebanon to invest in promoting governance to establish an accountability framework for all the concerned parties and strengthen IHR compliance. COVID-19 will not be the last public health emergency, and with all the compounded crises Lebanon has been assailed by, there is a considerable need to recognize the IHR framework as a fundamental cornerstone and incorporate all its capacities into the Lebanese health system. As stated by Benjamin Franklin, "By failing to prepare, you are preparing to fail."
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