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The Global Health Security Index

The Global Health Security (GHS) Index was first published in 2019 by the Nuclear Threat Initiative (NTI), Johns Hopkins Centre for Health Security, and the Economist Intelligence Unit.[[1]] It is a comprehensive, criteria-based assessment of health security capabilities across 195 States Parties to the International Health Regulations. The metric encompasses six categories relevant to health security and biological threats: Prevent, Detect, Respond, Health, Norms, and Risk (see Figure 1).

Figure 1: The six categories assessed by the Global Health Security Index.

Source: Nuclear Threat Initiative 2021 (Creative Commons).[[2]]

Evaluation work to generate the Index relies on publicly available information documenting preparedness as well as sustainable capabilities. The method used prioritises published information, functional systems, testing of systems and appropriate financing. In October 2019, the average global score was 40.2 out of 100.[[1]] No country was adequately prepared to face a biological threat. We have previously described the GHS Index in this Journal.[[3]]

On 8 December 2021, the NTI published a revised version of the GHS Index, with scoring updated based on evidence collected from August 2020 to June 2021.[[2]] The 2021 version of the GHS Index had been expanded considering lessons from the COVID-19 pandemic and the new version spans 37 indicators, 96 sub-indicators and 171 individual questions.

Criticisms of the GHS Index

The GHS Index has received criticism, some of which seems justified given research that has found poor correlation between GHS Index scores and a range of COVID-19 pandemic outcomes.[[4,5]] However, other studies have found the expected associations between higher scores and COVID-19 outcomes in Africa,[[6]] or in the first eight weeks after a country’s first case.[[7]] Razavi et al. questioned whether the items included skew towards the interests of high-income countries and whether the weighting of various items is appropriate.[[8]] Baum et al. presented ten factors that contributed to the Index’s failure to predict country COVID-19 responses, including overlooking political, economic, and social contexts and the role of civil society.[[9]] Rose et al. found that political and governance features not included in the Index had consistent correlations with COVID-19 outcome measures, and recommended inclusion in future iterations.[[10]] Benton et al. criticised the national focus of the Index, which perversely rewards hoarding of medicines and vaccines rather than equitable distribution of such resources.[[11]] Kaiser et al. concluded that the level of abstraction in global indices removed them from practical issues of policy on the ground.[[12]] However, all of the above criticisms were based on the earlier 2019 iteration of the GHS Index.

Importantly, the GHS Index cannot predict whether and how a country will make use of the capacities it has available during a public health emergency. Indeed, the GHS Index should probably not be used to compare dissimilar countries, which may have particular local or regional threats, or challenges and constraints. Identifying gaps and tracking change in score over time for each individual country is probably the more useful way of using the Index. Indeed, in the 2021 GHS Index report, the authors clarify that:

“Although countries are ranked using those scores, the GHS Index is a benchmarking tool that is scored on an absolute scale, meaning that gaps in any capacities could cripple countries in their response to health emergencies. As in cooking, a single missing ingredient can greatly change the outcome.” (p.19)

Validation of the GHS Index

In the face of criticisms specific to the context of COVID-19, our own assessment of the validity of the GHS Index found moderate validity in predicting key macro-indicators relevant to health security. Our peer-reviewed validation analysis of the 2019 version of the GHS Index[[13]] determined that:

• The GHS Index has face validity.

• The Index correlates strongly with other measures of health security.

• The Index correlates moderately with mortality from communicable diseases (see Figure 2).

• Countries that received health security aid have higher GHS Index scores than other countries matched by GDP and WHO region.

• GHS Index scores are typically higher for countries with experience of the SARS pandemic (2002–2004).

Figure 2: Communicable disease deaths (proportion of all deaths) and 2019 GHS Index score (F(3,172)=22.75, p<0.0001).[[13]]

Source: Authors’ published analysis (2020).[[13]]

More recently we have found an emerging correlation between 2019 GHS Index scores and the proportion of the population vaccinated against COVID-19 (see Figure 3). We conclude that the GHS Index is a somewhat valid measure of health security, perhaps best used by countries to identify gaps for further analysis and investment. Furthermore, this is exactly what the authors of the original GHS Index report intended and stated in their value proposition of the GHS Index.[[14]]

Figure 3: Overall GHS Index score 2019[[1]] and share of total population fully vaccinated against COVID-19 (as at 18 November 2021)[[15]] (Pearson’s r=0.58, p< 0.0001).

Source: Authors’ analysis for this viewpoint article.

GHS Index and lessons from the COVID-19 pandemic

The 2021 report details how the US “squandered” its world-leading capacities for pandemic response.[[2]] A key barrier was the lack of confidence in government, for which the US had the lowest possible score in the 2019 GHS Index. This factor has been associated with high numbers of COVID-19 cases and deaths in jurisdictions worldwide. Other gaps that had been identified prior to the pandemic included weaknesses in the US health system, limited access to care without cost barriers, and relatively few healthcare personnel and hospital beds per capita. Also, deficiencies in local capacities and capabilities could undermine national readiness.

When developing the 2021 iteration of the GHS Index, researchers took into account information and thinking about what had mattered most during the response to COVID-19. The result was the inclusion of additional socio-demographic, political, and governance variables; a revised Index with 171 rather than 140 items.

The revised GHS Index 2021

In the 2021 GHS Index, 31 questions have been added to address laboratory strength and quality, supply chains, medical stockpiles, isolation and contact tracing capability, national-level policies and plans, and government effectiveness. The researchers recalculated new “2019” scores using the revised Index and information that was available in 2019. This meant that progress from 2019 to 2021 was able to be assessed. It’s important to note that the GHS Index does not give full scores for temporary measures, so COVID-19 responses need to be associated with enduring systems and capacity targeting threats other than COVID-19 to score full marks.

GHS Index 2021 findings

The average country score for 2021 was 38.9 out of a possible 100 points, essentially unchanged from 2019. No country scored above 75.9 and the scores of the bottom 11 nations have all fallen since 2019.[[2]] Despite evidence of growing capacities, there remain major gaps in the capability to leverage these capacities to prevent, detect and respond to emerging biological threats. The US, for example, failed to turn their substantial capacities into a coordinated response to COVID-19. Improvements in response to the COVID-19 pandemic are frequently only temporary, and should be consolidated into robust systems with enduring finance to raise GHS Index scores. Key findings are summarised below.

Findings for 2021 across the six GHS Index categories[[2]]

• Prevention: This was the lowest scoring category in the GHS Index, in particular most countries direct little attention to zoonotic diseases.

• Detection and Reporting: Scores in 2021 reveal major global weaknesses in laboratory systems, laboratory supply chains, real-time surveillance, and reporting.

• Rapid Response: Only 69 countries have a national public health emergency response plan in place addressing multiple communicable diseases. COVID-19 has triggered some gains in non-pharmaceutical interventions planning.

• Health System: There has been little progress in health systems since 2019, with the 2021 Index finding that 91% of countries do not have a plan, programme, or guidelines in place for dispensing medical countermeasures.

• Commitments to Improving National Capacity, Financing, and Global Norms: Just four of 195 countries have identified funding in national budgets, which is dedicated to addressing gaps identified in their World Health Organization (WHO) Joint External Evaluation (JEE).

• Risk Environment: Awareness of risk environment factors, such as orderly transfer of power, social unrest, international tensions, and trust in medical and health advice from the government, is critical because of their large impact on countries’ response to a public health threat.

Additional important findings

• Most countries, including high-income nations, have not made dedicated financial investments in strengthening epidemic or pandemic preparedness.

• Most countries saw little or no improvement in maintaining a robust, capable, and accessible health system for outbreak detection and response.

• Political and security risks have increased in nearly all countries, and those with the fewest resources have the highest risk and greatest preparedness gaps.

• Countries are continuing to neglect the preparedness needs of vulnerable populations, exacerbating the impact of health security emergencies.

• Countries are not prepared to prevent globally catastrophic biological events that could cause damage on a larger scale than COVID-19.

GHS Index 2021 recommendations

The 2021 GHS Index report recommends action by countries, international organisations, the private sector and philanthropic organisations.[[2]] These recommendations are summarised below:

• Countries: Should ensure there are national budgets for building and maintaining health security capacities. The GHS Index and JEE evaluations can support development of National Action Plans for Public Health Security (NAPHS). There should be comprehensive after-action COVID-19 pandemic reports.

• The United Nations (UN), WHO and World Bank: Should use the GHS Index to identify major weaknesses and where urgent support is needed.

• Private Sector: Should use the GHS Index to partner with government to address gaps as well as increase sustainable development and health security R&D portfolios.

New Zealand and the Pacific

In the 2021 GHS Index, New Zealand scores 62.5/100, which is a rise of approximately 10% over 2019 scores, and New Zealand has risen to 13th globally (from 35th). This increase is driven in part by New Zealand’s completion of its JEE, and in part by positive developments in health security as part of the COVID-19 response. We caution, however, about too much focus on rankings, and emphasise that the function of the GHS Index is not necessarily to compare countries that may have quite different political or economic parameters, but rather to guide individual countries in assessments and investments in their own capacities.

Where previously we had lamented New Zealand’s relatively poor showing in the 2019 GHS Index[[3]] (including prior to the COVID-19 pandemic[[16]]), the 2021 report specifically highlights the country as “a case study in progress” (p.44). Stating that, “Country leaders cited preparedness assessments, specifically the GHS Index, as providing the roadmap and impetus for their exemplary performance during the Covid-19 pandemic.” This progress is promising, but the gains need to be consolidated, and persisting weaknesses addressed (see Table 1). The GHS assessment is supported by the observation that the elimination strategy adopted by New Zealand in response to an emerging pandemic (COVID-19) appears optimal, at least during the initial phase when vaccines and antivirals are not available.[[17]]

View Table 1.

We had also previously published our concerns about the generally low GHS Index scores of New Zealand’s Pacific neighbours.[[3]] No one expects that the GHS Index score of a country like Tuvalu will ever approach that of the US, but with scores in 2019 of around 20 out of 100, many Pacific nations were found to lack fundamental components of health security.

In the 2021 GHS Index, of 22 States scoring below 25/100, eight are island nations and six of these are in the Pacific. Nauru on 18.0 scored the least of the island nations and its score fell since 2019.

The relatively successful response of border closure has provided protection to some Pacific islands from the COVID-19 pandemic—and has given time for vaccination levels to rise. However, border closures cannot be indefinite, and cannot protect islands from a threat that originates within borders. Investment in key aspects of Pacific health security is therefore an ongoing requirement.

Focus on global catastrophic biological risks

The GHS Index report continues to have a focus on biological risks of unprecedented scale, that could have devastating outcomes for the world.[[2]] These global catastrophic biological risks (GCBRs) could be orders of magnitude worse than the COVID-19 pandemic. The probability of such events is almost certainly rising due to increasing urbanisation and human expansion, declining biodiversity and a changing climate, upticks in travel, trade, and terrorism, and the use of advanced biotechnologies in the absence of strong, normative guidance on responsible science.[[18]]

The authors of the GHS Index support the formation of an international body to promote early identification and reduction of GCBRs. The Index itself includes consideration of countries’ readiness for GCBRs through 21 sub-indicators, on which the mean global score is only 29.6 out of 100 (see Figure 4). The New Zealand Government may wish to pay particular attention to GCBRs—given that the country is an island,[[19,20]] and because it scores highly as one of the most favourable ones to survive a pandemic with existential risk potential.[[21,22]]

Figure 4: Global scores on 21 GHS Index items relevant to preparedness for global catastrophic biological risks (GCBRs), with New Zealand in the “East Asia and Pacific” grouping.

Source: Nuclear Threat Initiative 2021 (Creative Commons).[[2]]

Opportunities in New Zealand

New Zealand has the opportunity to focus its continuing large investment in its COVID-19 response on creating legacy benefits that will improve its health security.[[23]] Unfortunately, current indications are not promising that it will do this. The recently introduced Pae Ora (Healthy Futures) Bill that sets out a major new structure and arrangements for the health system contained very few specific measures to enhance health security.[[24]] In particular, it fails to specify the kind of independent public health agency needed to reduce the long-term erosion and fragmentation of public health capacity and capability.

Nevertheless, a large funding commitment to the proposed Public Health Agency within New Zealand’s Ministry of Health would be a potentially useful step, with a part of this devoted to improving capacity where the GHS Index benchmarks New Zealand as poorly prepared. As a starting point, the items we identify in Table 1 could be addressed. One example is ongoing disease surveillance. Such surveillance for COVID-19 in New Zealand continues to be suboptimal when compared for example to the UK’s Office for National Statistics Covid-19 infection survey, although the latter has also now been scaled back.[[25]] Similarly, New Zealand needs to keep funding its successful genomic sequencing capacity (as used with COVID-19[[26]]) and its detection of pathogens in wastewater (as also successfully used with COVID-19[[27]]). Wastewater surveillance for pathogens could even be extended to incoming international aircraft—as evaluated in an Australian setting.[[28]] It is programmes such as these, and for the prevention, detection and response to future infectious disease threats that are needed.

The new Māori Health Authority is a positive component of the current health reforms, and it could provide an equity lens to health security enhancements. In particular, it could review the experience of the COVID-19 pandemic from a Māori health and wellbeing perspective, and put this in context with how past pandemics have differentially impacted Māori.[[29]]

Conclusions

The 2021 iteration of the GHS Index provides an updated picture of global health security, with additional emphasis on aspects important through the COVID-19 pandemic. The key finding, again, is that the world remains grossly unprepared for emerging biological threats. That said, there are pockets of improvement, and New Zealand is specifically identified as a country that has bolstered its health security capacity during the pandemic. However, at 62.5/100 there is clearly much more that New Zealand can do to secure protection from future health disaster.

The report emphasises the distinction between capacity and capability. Capacity alone is not enough. Capacities must be exercised and integrated, and governance must be able to ensure they are leveraged when needed. This is capability. Without regular assessments of capacities and capabilities, governments cannot know their levels of preparedness.

A great opportunity exists to develop new capacities and make existing ones more durable, ensuring long-term gains in pandemic preparedness. The GHS Index helps identify important gaps, but, given the course of the COVID-19 pandemic, we may also need assessments that monitor the actual performance of health systems against emerging infectious diseases.

Summary

Abstract

The 2021 Global Health Security (GHS) Index Report was published on 8 December 2021. With an average country score of 38.9 out of a possible 100 points, global scores are essentially unchanged from 2019. Despite experience with the COVID-19 pandemic, no country is adequately prepared for future biological threats. No country scored above 75.9 and the scores of the bottom 11 States have all fallen since 2019. Aotearoa New Zealand, however, has substantially improved its country score, rising to 13th in the world at 62.5/100. This gain is partly driven by consolidation of capabilities developed and deployed in response to COVID-19. This is promising progress, but a lot more can be done to ensure legacy benefits from the pandemic response, notably through the proposed restructuring of the health system (Pae Ora (Healthy Futures) Bill). In this viewpoint article, we discuss this recent further development of the GHS Index, highlight the global results for 2021, delve into New Zealand’s progress, and discuss what more is needed.

Aim

Method

Results

Conclusion

Author Information

Dr Matt Boyd: Research Director, Adapt Research Ltd, Reefton, New Zealand. Prof Michael G Baker: School of Public Health, University of Otago, Wellington, New Zealand. Dr Cassidy Nelson: Future of Humanity Institute, University of Oxford, Oxford, United Kingdom. Prof Nick Wilson: School of Public Health, University of Otago, Wellington, New Zealand.

Acknowledgements

Correspondence

Dr Matt Boyd: Research Director, Adapt Research Ltd, 14 Broadway, Reefton 7830, New Zealand. Ph: +64223512350

Correspondence Email

matt@adaptresearchwriting.com

Competing Interests

Nil.

1) Cameron E, Nuzzo J, Bell J. Global Health Security Index: Building Collective Action and Accountability: Nuclear Threat Initiative and Johns Hopkins Bloomberg School of Public Health. 2019. https://www.ghsindex.org/wp-content/uploads/2019/10/2019-Global-Health-Security-Index.pdf.

2) Bell J, Nuzzo J. Global Health Security Index: Advancing Collective Action and Accountability Amid Global Crisis: Nuclear Threat Institute. 2021. https://www.ghsindex.org/.

3) Boyd M, Baker M, Nelson C, et al. The 2019 Global Health Security Index (GHSI) and its Implications for Pacific Regional Health Security. N Z Med J. 2020;133:83-92.

4) Haider N, Yavlinsky A, Chang YM, et al. The Global Health Security index and Joint External Evaluation score for health preparedness are not correlated with countries' COVID-19 detection response time and mortality outcome. Epidemiol Infect. 2020;148:e210. doi:10.1017/s0950268820002046.

5) Kim J, Hong K, Yum S, et al. Factors associated with the difference between the incidence and case-fatality ratio of coronavirus disease 2019 by country. Sci Rep. 2021;11:18938. doi:10.1038/s41598-021-98378-x [published Online First: 2021/09/25].

6) Amadu I, Ahinkorah BO, Afitiri AR, et al. Assessing sub-regional-specific strengths of healthcare systems associated with COVID-19 prevalence, deaths and recoveries in Africa. PLoS One. 2021;16:e0247274. doi:10.1371/journal.pone.0247274 [published Online First: 2021/03/02].

7) Duong DB, King AJ, Grépin KA, et al. Strengthening national capacities for pandemic preparedness: a cross-country analysis of COVID-19 cases and deaths. Health Policy Plan. 2022;37:55–64. doi:10.1093/heapol/czab122 [published Online First: 2021/10/06].

8) Razavi A, Erondu N, Okereke E. The Global Health Security Index: what value does it add? BMJ Global Health. 2020;5:e002477. doi:10.1136/bmjgh-2020-002477.

9) Baum F, Freeman T, Musolino C, et al. Explaining covid-19 performance: what factors might predict national responses? BMJ. 2021;372:n91. doi: 10.1136/bmj.n91.

10) Rose SM, Paterra M, Isaac C, et al. Analysing COVID-19 outcomes in the context of the 2019 Global Health Security (GHS) Index. BMJ Glob Health. 2021;6(12). doi:10.1136/bmjgh-2021-007581 [published Online First: 2021/12/12].

11) Benton A, Majumder M, Yamey G. The global health security agenda rewards rich nations for their selfish behaviour: the BMJ opinion. 2021 [Available from: https://blogs.bmj.com/bmj/2021/08/20/the-global-health-security-agenda-rewards-rich-nations-for-their-selfish-behaviour/ [accessed 15 December 2021].

12) Kaiser M, Chen AT, Gluckman P. Should policy makers trust composite indices? A commentary on the pitfalls of inappropriate indices for policy formation. Health Res Policy Syst. 2021;19:40. doi:10.1186/s12961-021-00702-4 [published Online First: 2021/03/24].

13) Boyd M, Wilson N, Nelson C. Validation analysis of global health security index (GHSI) scores 2019. BMJ Glob Health. 2020;5:e003276.

14) Ravi SJ, Warmbrod KL, Mullen L, et al. The value proposition of the Global Health Security Index. BMJ Glob Health. 2020;5:e003648. doi: 10.1136/bmjgh-2020-003648.

15) Mathieu E, Ritchie H, Ortiz-Ospina E, et al. A global database of COVID-19 vaccinations. Nat Hum Behav. 2021;5:947-53. doi:10.1038/s41562-021-01122-8.

16) Boyd M, Baker M, Wilson N. New Zealand’s Poor Pandemic Preparedness According to the Global Health Security Index. Public Health Expert (Blog). 2019;(11 November). https://blogs.otago.ac.nz/pubhealthexpert/new-zealands-poor-pandemic-preparedness-according-to-the-global-health-security-index/.

17) Baker MG, Wilson N, Blakely T. Elimination could be the optimal response strategy for covid-19 and other emerging pandemic diseases. BMJ. 2020;371:m4907. doi: 10.1136/bmj.m4907.

18) Cameron EE. Emerging and Converging Global Catastrophic Biological Risks. Health Secur. 2017;15:337-38. doi:10.1089/hs.2017.0043 [published Online First: 2017/07/26].

19) Boyd M, Mansoor OD, Baker MG, et al. Economic evaluation of border closure for a generic severe pandemic threat using New Zealand Treasury methods. Aust N Z J Public Health. 2018;42:444-46. doi:10.1111/1753-6405.12818 [published Online First: 2018/08/09].

20) Boyd M, Baker MG, Wilson N. Border closure for island nations? Analysis of pandemic and bioweapon-related threats suggests some scenarios warrant drastic action. Aust N Z J Public Health. 2020;44:89-91. doi: 10.1111/1753-6405.12991 [published Online First: 2020/04/08].

21) Boyd M, Wilson N. The Prioritization of Island Nations as Refuges from Extreme Pandemics. Risk Anal. 2020;40:227-39. doi:10.1111/risa.13398 [published Online First: 2019/09/24].

22) Boyd M, Wilson N. Optimizing Island Refuges against global Catastrophic and Existential Biological Threats: Priorities and Preparations. Risk Anal. 2021;41:2266–85. doi: 10.1111/risa.13735 [published Online First: 2021/04/23].

23) Baker MG, Kvalsvig A, Crengle S, et al. The next phase in Aotearoa New Zealand's COVID-19 response: a tight suppression strategy may be the best option. N Z Med J. 2021;134:8-16. [published Online First: 2021/12/03.]

24) NZ Parliament. Pae Ora (Healthy Futures) Bill, 2021. https://www.parliament.nz/en/pb/bills-and-laws/bills-proposed-laws/document/BILL_116317/pae-ora-healthy-futures-bill.

25) Clarke J, Beaney T, Majeed A. UK scales back routine covid-19 surveillance. BMJ. 2022;376:o562. doi: 10.1136/bmj.o562.

26) Geoghegan JL, Douglas J, Ren X, et al. Use of genomics to track coronavirus disease outbreaks, New Zealand. Emerging Infect Dis. 2021;27:1317. doi: 10.3201/eid2705.204579.

27) Hewitt J, Trowsdale S, Armstrong B, et al. Sensitivity of wastewater-based epidemiology for detection of SARS-CoV-2 RNA in a low prevalence setting. Water Research. 2022:118032. doi:10.1016/j.watres.2021.118032.

28) Ahmed W, Bivins A, Simpson SL, et al. Wastewater surveillance demonstrates high predictive value for COVID-19 infection on board repatriation flights to Australia. Environment International. 2022;158:106938. doi:10.1016/j.envint.2021.106938.

29) Wilson N, Telfar Barnard L, Summers J, et al. Differential mortality by ethnicity in 3 influenza pandemics over a century, New Zealand. Emerg Infect Dis. 2012;18:71-77. doi:10.3201/eid1801.110035.

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The Global Health Security Index

The Global Health Security (GHS) Index was first published in 2019 by the Nuclear Threat Initiative (NTI), Johns Hopkins Centre for Health Security, and the Economist Intelligence Unit.[[1]] It is a comprehensive, criteria-based assessment of health security capabilities across 195 States Parties to the International Health Regulations. The metric encompasses six categories relevant to health security and biological threats: Prevent, Detect, Respond, Health, Norms, and Risk (see Figure 1).

Figure 1: The six categories assessed by the Global Health Security Index.

Source: Nuclear Threat Initiative 2021 (Creative Commons).[[2]]

Evaluation work to generate the Index relies on publicly available information documenting preparedness as well as sustainable capabilities. The method used prioritises published information, functional systems, testing of systems and appropriate financing. In October 2019, the average global score was 40.2 out of 100.[[1]] No country was adequately prepared to face a biological threat. We have previously described the GHS Index in this Journal.[[3]]

On 8 December 2021, the NTI published a revised version of the GHS Index, with scoring updated based on evidence collected from August 2020 to June 2021.[[2]] The 2021 version of the GHS Index had been expanded considering lessons from the COVID-19 pandemic and the new version spans 37 indicators, 96 sub-indicators and 171 individual questions.

Criticisms of the GHS Index

The GHS Index has received criticism, some of which seems justified given research that has found poor correlation between GHS Index scores and a range of COVID-19 pandemic outcomes.[[4,5]] However, other studies have found the expected associations between higher scores and COVID-19 outcomes in Africa,[[6]] or in the first eight weeks after a country’s first case.[[7]] Razavi et al. questioned whether the items included skew towards the interests of high-income countries and whether the weighting of various items is appropriate.[[8]] Baum et al. presented ten factors that contributed to the Index’s failure to predict country COVID-19 responses, including overlooking political, economic, and social contexts and the role of civil society.[[9]] Rose et al. found that political and governance features not included in the Index had consistent correlations with COVID-19 outcome measures, and recommended inclusion in future iterations.[[10]] Benton et al. criticised the national focus of the Index, which perversely rewards hoarding of medicines and vaccines rather than equitable distribution of such resources.[[11]] Kaiser et al. concluded that the level of abstraction in global indices removed them from practical issues of policy on the ground.[[12]] However, all of the above criticisms were based on the earlier 2019 iteration of the GHS Index.

Importantly, the GHS Index cannot predict whether and how a country will make use of the capacities it has available during a public health emergency. Indeed, the GHS Index should probably not be used to compare dissimilar countries, which may have particular local or regional threats, or challenges and constraints. Identifying gaps and tracking change in score over time for each individual country is probably the more useful way of using the Index. Indeed, in the 2021 GHS Index report, the authors clarify that:

“Although countries are ranked using those scores, the GHS Index is a benchmarking tool that is scored on an absolute scale, meaning that gaps in any capacities could cripple countries in their response to health emergencies. As in cooking, a single missing ingredient can greatly change the outcome.” (p.19)

Validation of the GHS Index

In the face of criticisms specific to the context of COVID-19, our own assessment of the validity of the GHS Index found moderate validity in predicting key macro-indicators relevant to health security. Our peer-reviewed validation analysis of the 2019 version of the GHS Index[[13]] determined that:

• The GHS Index has face validity.

• The Index correlates strongly with other measures of health security.

• The Index correlates moderately with mortality from communicable diseases (see Figure 2).

• Countries that received health security aid have higher GHS Index scores than other countries matched by GDP and WHO region.

• GHS Index scores are typically higher for countries with experience of the SARS pandemic (2002–2004).

Figure 2: Communicable disease deaths (proportion of all deaths) and 2019 GHS Index score (F(3,172)=22.75, p<0.0001).[[13]]

Source: Authors’ published analysis (2020).[[13]]

More recently we have found an emerging correlation between 2019 GHS Index scores and the proportion of the population vaccinated against COVID-19 (see Figure 3). We conclude that the GHS Index is a somewhat valid measure of health security, perhaps best used by countries to identify gaps for further analysis and investment. Furthermore, this is exactly what the authors of the original GHS Index report intended and stated in their value proposition of the GHS Index.[[14]]

Figure 3: Overall GHS Index score 2019[[1]] and share of total population fully vaccinated against COVID-19 (as at 18 November 2021)[[15]] (Pearson’s r=0.58, p< 0.0001).

Source: Authors’ analysis for this viewpoint article.

GHS Index and lessons from the COVID-19 pandemic

The 2021 report details how the US “squandered” its world-leading capacities for pandemic response.[[2]] A key barrier was the lack of confidence in government, for which the US had the lowest possible score in the 2019 GHS Index. This factor has been associated with high numbers of COVID-19 cases and deaths in jurisdictions worldwide. Other gaps that had been identified prior to the pandemic included weaknesses in the US health system, limited access to care without cost barriers, and relatively few healthcare personnel and hospital beds per capita. Also, deficiencies in local capacities and capabilities could undermine national readiness.

When developing the 2021 iteration of the GHS Index, researchers took into account information and thinking about what had mattered most during the response to COVID-19. The result was the inclusion of additional socio-demographic, political, and governance variables; a revised Index with 171 rather than 140 items.

The revised GHS Index 2021

In the 2021 GHS Index, 31 questions have been added to address laboratory strength and quality, supply chains, medical stockpiles, isolation and contact tracing capability, national-level policies and plans, and government effectiveness. The researchers recalculated new “2019” scores using the revised Index and information that was available in 2019. This meant that progress from 2019 to 2021 was able to be assessed. It’s important to note that the GHS Index does not give full scores for temporary measures, so COVID-19 responses need to be associated with enduring systems and capacity targeting threats other than COVID-19 to score full marks.

GHS Index 2021 findings

The average country score for 2021 was 38.9 out of a possible 100 points, essentially unchanged from 2019. No country scored above 75.9 and the scores of the bottom 11 nations have all fallen since 2019.[[2]] Despite evidence of growing capacities, there remain major gaps in the capability to leverage these capacities to prevent, detect and respond to emerging biological threats. The US, for example, failed to turn their substantial capacities into a coordinated response to COVID-19. Improvements in response to the COVID-19 pandemic are frequently only temporary, and should be consolidated into robust systems with enduring finance to raise GHS Index scores. Key findings are summarised below.

Findings for 2021 across the six GHS Index categories[[2]]

• Prevention: This was the lowest scoring category in the GHS Index, in particular most countries direct little attention to zoonotic diseases.

• Detection and Reporting: Scores in 2021 reveal major global weaknesses in laboratory systems, laboratory supply chains, real-time surveillance, and reporting.

• Rapid Response: Only 69 countries have a national public health emergency response plan in place addressing multiple communicable diseases. COVID-19 has triggered some gains in non-pharmaceutical interventions planning.

• Health System: There has been little progress in health systems since 2019, with the 2021 Index finding that 91% of countries do not have a plan, programme, or guidelines in place for dispensing medical countermeasures.

• Commitments to Improving National Capacity, Financing, and Global Norms: Just four of 195 countries have identified funding in national budgets, which is dedicated to addressing gaps identified in their World Health Organization (WHO) Joint External Evaluation (JEE).

• Risk Environment: Awareness of risk environment factors, such as orderly transfer of power, social unrest, international tensions, and trust in medical and health advice from the government, is critical because of their large impact on countries’ response to a public health threat.

Additional important findings

• Most countries, including high-income nations, have not made dedicated financial investments in strengthening epidemic or pandemic preparedness.

• Most countries saw little or no improvement in maintaining a robust, capable, and accessible health system for outbreak detection and response.

• Political and security risks have increased in nearly all countries, and those with the fewest resources have the highest risk and greatest preparedness gaps.

• Countries are continuing to neglect the preparedness needs of vulnerable populations, exacerbating the impact of health security emergencies.

• Countries are not prepared to prevent globally catastrophic biological events that could cause damage on a larger scale than COVID-19.

GHS Index 2021 recommendations

The 2021 GHS Index report recommends action by countries, international organisations, the private sector and philanthropic organisations.[[2]] These recommendations are summarised below:

• Countries: Should ensure there are national budgets for building and maintaining health security capacities. The GHS Index and JEE evaluations can support development of National Action Plans for Public Health Security (NAPHS). There should be comprehensive after-action COVID-19 pandemic reports.

• The United Nations (UN), WHO and World Bank: Should use the GHS Index to identify major weaknesses and where urgent support is needed.

• Private Sector: Should use the GHS Index to partner with government to address gaps as well as increase sustainable development and health security R&D portfolios.

New Zealand and the Pacific

In the 2021 GHS Index, New Zealand scores 62.5/100, which is a rise of approximately 10% over 2019 scores, and New Zealand has risen to 13th globally (from 35th). This increase is driven in part by New Zealand’s completion of its JEE, and in part by positive developments in health security as part of the COVID-19 response. We caution, however, about too much focus on rankings, and emphasise that the function of the GHS Index is not necessarily to compare countries that may have quite different political or economic parameters, but rather to guide individual countries in assessments and investments in their own capacities.

Where previously we had lamented New Zealand’s relatively poor showing in the 2019 GHS Index[[3]] (including prior to the COVID-19 pandemic[[16]]), the 2021 report specifically highlights the country as “a case study in progress” (p.44). Stating that, “Country leaders cited preparedness assessments, specifically the GHS Index, as providing the roadmap and impetus for their exemplary performance during the Covid-19 pandemic.” This progress is promising, but the gains need to be consolidated, and persisting weaknesses addressed (see Table 1). The GHS assessment is supported by the observation that the elimination strategy adopted by New Zealand in response to an emerging pandemic (COVID-19) appears optimal, at least during the initial phase when vaccines and antivirals are not available.[[17]]

View Table 1.

We had also previously published our concerns about the generally low GHS Index scores of New Zealand’s Pacific neighbours.[[3]] No one expects that the GHS Index score of a country like Tuvalu will ever approach that of the US, but with scores in 2019 of around 20 out of 100, many Pacific nations were found to lack fundamental components of health security.

In the 2021 GHS Index, of 22 States scoring below 25/100, eight are island nations and six of these are in the Pacific. Nauru on 18.0 scored the least of the island nations and its score fell since 2019.

The relatively successful response of border closure has provided protection to some Pacific islands from the COVID-19 pandemic—and has given time for vaccination levels to rise. However, border closures cannot be indefinite, and cannot protect islands from a threat that originates within borders. Investment in key aspects of Pacific health security is therefore an ongoing requirement.

Focus on global catastrophic biological risks

The GHS Index report continues to have a focus on biological risks of unprecedented scale, that could have devastating outcomes for the world.[[2]] These global catastrophic biological risks (GCBRs) could be orders of magnitude worse than the COVID-19 pandemic. The probability of such events is almost certainly rising due to increasing urbanisation and human expansion, declining biodiversity and a changing climate, upticks in travel, trade, and terrorism, and the use of advanced biotechnologies in the absence of strong, normative guidance on responsible science.[[18]]

The authors of the GHS Index support the formation of an international body to promote early identification and reduction of GCBRs. The Index itself includes consideration of countries’ readiness for GCBRs through 21 sub-indicators, on which the mean global score is only 29.6 out of 100 (see Figure 4). The New Zealand Government may wish to pay particular attention to GCBRs—given that the country is an island,[[19,20]] and because it scores highly as one of the most favourable ones to survive a pandemic with existential risk potential.[[21,22]]

Figure 4: Global scores on 21 GHS Index items relevant to preparedness for global catastrophic biological risks (GCBRs), with New Zealand in the “East Asia and Pacific” grouping.

Source: Nuclear Threat Initiative 2021 (Creative Commons).[[2]]

Opportunities in New Zealand

New Zealand has the opportunity to focus its continuing large investment in its COVID-19 response on creating legacy benefits that will improve its health security.[[23]] Unfortunately, current indications are not promising that it will do this. The recently introduced Pae Ora (Healthy Futures) Bill that sets out a major new structure and arrangements for the health system contained very few specific measures to enhance health security.[[24]] In particular, it fails to specify the kind of independent public health agency needed to reduce the long-term erosion and fragmentation of public health capacity and capability.

Nevertheless, a large funding commitment to the proposed Public Health Agency within New Zealand’s Ministry of Health would be a potentially useful step, with a part of this devoted to improving capacity where the GHS Index benchmarks New Zealand as poorly prepared. As a starting point, the items we identify in Table 1 could be addressed. One example is ongoing disease surveillance. Such surveillance for COVID-19 in New Zealand continues to be suboptimal when compared for example to the UK’s Office for National Statistics Covid-19 infection survey, although the latter has also now been scaled back.[[25]] Similarly, New Zealand needs to keep funding its successful genomic sequencing capacity (as used with COVID-19[[26]]) and its detection of pathogens in wastewater (as also successfully used with COVID-19[[27]]). Wastewater surveillance for pathogens could even be extended to incoming international aircraft—as evaluated in an Australian setting.[[28]] It is programmes such as these, and for the prevention, detection and response to future infectious disease threats that are needed.

The new Māori Health Authority is a positive component of the current health reforms, and it could provide an equity lens to health security enhancements. In particular, it could review the experience of the COVID-19 pandemic from a Māori health and wellbeing perspective, and put this in context with how past pandemics have differentially impacted Māori.[[29]]

Conclusions

The 2021 iteration of the GHS Index provides an updated picture of global health security, with additional emphasis on aspects important through the COVID-19 pandemic. The key finding, again, is that the world remains grossly unprepared for emerging biological threats. That said, there are pockets of improvement, and New Zealand is specifically identified as a country that has bolstered its health security capacity during the pandemic. However, at 62.5/100 there is clearly much more that New Zealand can do to secure protection from future health disaster.

The report emphasises the distinction between capacity and capability. Capacity alone is not enough. Capacities must be exercised and integrated, and governance must be able to ensure they are leveraged when needed. This is capability. Without regular assessments of capacities and capabilities, governments cannot know their levels of preparedness.

A great opportunity exists to develop new capacities and make existing ones more durable, ensuring long-term gains in pandemic preparedness. The GHS Index helps identify important gaps, but, given the course of the COVID-19 pandemic, we may also need assessments that monitor the actual performance of health systems against emerging infectious diseases.

Summary

Abstract

The 2021 Global Health Security (GHS) Index Report was published on 8 December 2021. With an average country score of 38.9 out of a possible 100 points, global scores are essentially unchanged from 2019. Despite experience with the COVID-19 pandemic, no country is adequately prepared for future biological threats. No country scored above 75.9 and the scores of the bottom 11 States have all fallen since 2019. Aotearoa New Zealand, however, has substantially improved its country score, rising to 13th in the world at 62.5/100. This gain is partly driven by consolidation of capabilities developed and deployed in response to COVID-19. This is promising progress, but a lot more can be done to ensure legacy benefits from the pandemic response, notably through the proposed restructuring of the health system (Pae Ora (Healthy Futures) Bill). In this viewpoint article, we discuss this recent further development of the GHS Index, highlight the global results for 2021, delve into New Zealand’s progress, and discuss what more is needed.

Aim

Method

Results

Conclusion

Author Information

Dr Matt Boyd: Research Director, Adapt Research Ltd, Reefton, New Zealand. Prof Michael G Baker: School of Public Health, University of Otago, Wellington, New Zealand. Dr Cassidy Nelson: Future of Humanity Institute, University of Oxford, Oxford, United Kingdom. Prof Nick Wilson: School of Public Health, University of Otago, Wellington, New Zealand.

Acknowledgements

Correspondence

Dr Matt Boyd: Research Director, Adapt Research Ltd, 14 Broadway, Reefton 7830, New Zealand. Ph: +64223512350

Correspondence Email

matt@adaptresearchwriting.com

Competing Interests

Nil.

1) Cameron E, Nuzzo J, Bell J. Global Health Security Index: Building Collective Action and Accountability: Nuclear Threat Initiative and Johns Hopkins Bloomberg School of Public Health. 2019. https://www.ghsindex.org/wp-content/uploads/2019/10/2019-Global-Health-Security-Index.pdf.

2) Bell J, Nuzzo J. Global Health Security Index: Advancing Collective Action and Accountability Amid Global Crisis: Nuclear Threat Institute. 2021. https://www.ghsindex.org/.

3) Boyd M, Baker M, Nelson C, et al. The 2019 Global Health Security Index (GHSI) and its Implications for Pacific Regional Health Security. N Z Med J. 2020;133:83-92.

4) Haider N, Yavlinsky A, Chang YM, et al. The Global Health Security index and Joint External Evaluation score for health preparedness are not correlated with countries' COVID-19 detection response time and mortality outcome. Epidemiol Infect. 2020;148:e210. doi:10.1017/s0950268820002046.

5) Kim J, Hong K, Yum S, et al. Factors associated with the difference between the incidence and case-fatality ratio of coronavirus disease 2019 by country. Sci Rep. 2021;11:18938. doi:10.1038/s41598-021-98378-x [published Online First: 2021/09/25].

6) Amadu I, Ahinkorah BO, Afitiri AR, et al. Assessing sub-regional-specific strengths of healthcare systems associated with COVID-19 prevalence, deaths and recoveries in Africa. PLoS One. 2021;16:e0247274. doi:10.1371/journal.pone.0247274 [published Online First: 2021/03/02].

7) Duong DB, King AJ, Grépin KA, et al. Strengthening national capacities for pandemic preparedness: a cross-country analysis of COVID-19 cases and deaths. Health Policy Plan. 2022;37:55–64. doi:10.1093/heapol/czab122 [published Online First: 2021/10/06].

8) Razavi A, Erondu N, Okereke E. The Global Health Security Index: what value does it add? BMJ Global Health. 2020;5:e002477. doi:10.1136/bmjgh-2020-002477.

9) Baum F, Freeman T, Musolino C, et al. Explaining covid-19 performance: what factors might predict national responses? BMJ. 2021;372:n91. doi: 10.1136/bmj.n91.

10) Rose SM, Paterra M, Isaac C, et al. Analysing COVID-19 outcomes in the context of the 2019 Global Health Security (GHS) Index. BMJ Glob Health. 2021;6(12). doi:10.1136/bmjgh-2021-007581 [published Online First: 2021/12/12].

11) Benton A, Majumder M, Yamey G. The global health security agenda rewards rich nations for their selfish behaviour: the BMJ opinion. 2021 [Available from: https://blogs.bmj.com/bmj/2021/08/20/the-global-health-security-agenda-rewards-rich-nations-for-their-selfish-behaviour/ [accessed 15 December 2021].

12) Kaiser M, Chen AT, Gluckman P. Should policy makers trust composite indices? A commentary on the pitfalls of inappropriate indices for policy formation. Health Res Policy Syst. 2021;19:40. doi:10.1186/s12961-021-00702-4 [published Online First: 2021/03/24].

13) Boyd M, Wilson N, Nelson C. Validation analysis of global health security index (GHSI) scores 2019. BMJ Glob Health. 2020;5:e003276.

14) Ravi SJ, Warmbrod KL, Mullen L, et al. The value proposition of the Global Health Security Index. BMJ Glob Health. 2020;5:e003648. doi: 10.1136/bmjgh-2020-003648.

15) Mathieu E, Ritchie H, Ortiz-Ospina E, et al. A global database of COVID-19 vaccinations. Nat Hum Behav. 2021;5:947-53. doi:10.1038/s41562-021-01122-8.

16) Boyd M, Baker M, Wilson N. New Zealand’s Poor Pandemic Preparedness According to the Global Health Security Index. Public Health Expert (Blog). 2019;(11 November). https://blogs.otago.ac.nz/pubhealthexpert/new-zealands-poor-pandemic-preparedness-according-to-the-global-health-security-index/.

17) Baker MG, Wilson N, Blakely T. Elimination could be the optimal response strategy for covid-19 and other emerging pandemic diseases. BMJ. 2020;371:m4907. doi: 10.1136/bmj.m4907.

18) Cameron EE. Emerging and Converging Global Catastrophic Biological Risks. Health Secur. 2017;15:337-38. doi:10.1089/hs.2017.0043 [published Online First: 2017/07/26].

19) Boyd M, Mansoor OD, Baker MG, et al. Economic evaluation of border closure for a generic severe pandemic threat using New Zealand Treasury methods. Aust N Z J Public Health. 2018;42:444-46. doi:10.1111/1753-6405.12818 [published Online First: 2018/08/09].

20) Boyd M, Baker MG, Wilson N. Border closure for island nations? Analysis of pandemic and bioweapon-related threats suggests some scenarios warrant drastic action. Aust N Z J Public Health. 2020;44:89-91. doi: 10.1111/1753-6405.12991 [published Online First: 2020/04/08].

21) Boyd M, Wilson N. The Prioritization of Island Nations as Refuges from Extreme Pandemics. Risk Anal. 2020;40:227-39. doi:10.1111/risa.13398 [published Online First: 2019/09/24].

22) Boyd M, Wilson N. Optimizing Island Refuges against global Catastrophic and Existential Biological Threats: Priorities and Preparations. Risk Anal. 2021;41:2266–85. doi: 10.1111/risa.13735 [published Online First: 2021/04/23].

23) Baker MG, Kvalsvig A, Crengle S, et al. The next phase in Aotearoa New Zealand's COVID-19 response: a tight suppression strategy may be the best option. N Z Med J. 2021;134:8-16. [published Online First: 2021/12/03.]

24) NZ Parliament. Pae Ora (Healthy Futures) Bill, 2021. https://www.parliament.nz/en/pb/bills-and-laws/bills-proposed-laws/document/BILL_116317/pae-ora-healthy-futures-bill.

25) Clarke J, Beaney T, Majeed A. UK scales back routine covid-19 surveillance. BMJ. 2022;376:o562. doi: 10.1136/bmj.o562.

26) Geoghegan JL, Douglas J, Ren X, et al. Use of genomics to track coronavirus disease outbreaks, New Zealand. Emerging Infect Dis. 2021;27:1317. doi: 10.3201/eid2705.204579.

27) Hewitt J, Trowsdale S, Armstrong B, et al. Sensitivity of wastewater-based epidemiology for detection of SARS-CoV-2 RNA in a low prevalence setting. Water Research. 2022:118032. doi:10.1016/j.watres.2021.118032.

28) Ahmed W, Bivins A, Simpson SL, et al. Wastewater surveillance demonstrates high predictive value for COVID-19 infection on board repatriation flights to Australia. Environment International. 2022;158:106938. doi:10.1016/j.envint.2021.106938.

29) Wilson N, Telfar Barnard L, Summers J, et al. Differential mortality by ethnicity in 3 influenza pandemics over a century, New Zealand. Emerg Infect Dis. 2012;18:71-77. doi:10.3201/eid1801.110035.

For the PDF of this article,
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The Global Health Security Index

The Global Health Security (GHS) Index was first published in 2019 by the Nuclear Threat Initiative (NTI), Johns Hopkins Centre for Health Security, and the Economist Intelligence Unit.[[1]] It is a comprehensive, criteria-based assessment of health security capabilities across 195 States Parties to the International Health Regulations. The metric encompasses six categories relevant to health security and biological threats: Prevent, Detect, Respond, Health, Norms, and Risk (see Figure 1).

Figure 1: The six categories assessed by the Global Health Security Index.

Source: Nuclear Threat Initiative 2021 (Creative Commons).[[2]]

Evaluation work to generate the Index relies on publicly available information documenting preparedness as well as sustainable capabilities. The method used prioritises published information, functional systems, testing of systems and appropriate financing. In October 2019, the average global score was 40.2 out of 100.[[1]] No country was adequately prepared to face a biological threat. We have previously described the GHS Index in this Journal.[[3]]

On 8 December 2021, the NTI published a revised version of the GHS Index, with scoring updated based on evidence collected from August 2020 to June 2021.[[2]] The 2021 version of the GHS Index had been expanded considering lessons from the COVID-19 pandemic and the new version spans 37 indicators, 96 sub-indicators and 171 individual questions.

Criticisms of the GHS Index

The GHS Index has received criticism, some of which seems justified given research that has found poor correlation between GHS Index scores and a range of COVID-19 pandemic outcomes.[[4,5]] However, other studies have found the expected associations between higher scores and COVID-19 outcomes in Africa,[[6]] or in the first eight weeks after a country’s first case.[[7]] Razavi et al. questioned whether the items included skew towards the interests of high-income countries and whether the weighting of various items is appropriate.[[8]] Baum et al. presented ten factors that contributed to the Index’s failure to predict country COVID-19 responses, including overlooking political, economic, and social contexts and the role of civil society.[[9]] Rose et al. found that political and governance features not included in the Index had consistent correlations with COVID-19 outcome measures, and recommended inclusion in future iterations.[[10]] Benton et al. criticised the national focus of the Index, which perversely rewards hoarding of medicines and vaccines rather than equitable distribution of such resources.[[11]] Kaiser et al. concluded that the level of abstraction in global indices removed them from practical issues of policy on the ground.[[12]] However, all of the above criticisms were based on the earlier 2019 iteration of the GHS Index.

Importantly, the GHS Index cannot predict whether and how a country will make use of the capacities it has available during a public health emergency. Indeed, the GHS Index should probably not be used to compare dissimilar countries, which may have particular local or regional threats, or challenges and constraints. Identifying gaps and tracking change in score over time for each individual country is probably the more useful way of using the Index. Indeed, in the 2021 GHS Index report, the authors clarify that:

“Although countries are ranked using those scores, the GHS Index is a benchmarking tool that is scored on an absolute scale, meaning that gaps in any capacities could cripple countries in their response to health emergencies. As in cooking, a single missing ingredient can greatly change the outcome.” (p.19)

Validation of the GHS Index

In the face of criticisms specific to the context of COVID-19, our own assessment of the validity of the GHS Index found moderate validity in predicting key macro-indicators relevant to health security. Our peer-reviewed validation analysis of the 2019 version of the GHS Index[[13]] determined that:

• The GHS Index has face validity.

• The Index correlates strongly with other measures of health security.

• The Index correlates moderately with mortality from communicable diseases (see Figure 2).

• Countries that received health security aid have higher GHS Index scores than other countries matched by GDP and WHO region.

• GHS Index scores are typically higher for countries with experience of the SARS pandemic (2002–2004).

Figure 2: Communicable disease deaths (proportion of all deaths) and 2019 GHS Index score (F(3,172)=22.75, p<0.0001).[[13]]

Source: Authors’ published analysis (2020).[[13]]

More recently we have found an emerging correlation between 2019 GHS Index scores and the proportion of the population vaccinated against COVID-19 (see Figure 3). We conclude that the GHS Index is a somewhat valid measure of health security, perhaps best used by countries to identify gaps for further analysis and investment. Furthermore, this is exactly what the authors of the original GHS Index report intended and stated in their value proposition of the GHS Index.[[14]]

Figure 3: Overall GHS Index score 2019[[1]] and share of total population fully vaccinated against COVID-19 (as at 18 November 2021)[[15]] (Pearson’s r=0.58, p< 0.0001).

Source: Authors’ analysis for this viewpoint article.

GHS Index and lessons from the COVID-19 pandemic

The 2021 report details how the US “squandered” its world-leading capacities for pandemic response.[[2]] A key barrier was the lack of confidence in government, for which the US had the lowest possible score in the 2019 GHS Index. This factor has been associated with high numbers of COVID-19 cases and deaths in jurisdictions worldwide. Other gaps that had been identified prior to the pandemic included weaknesses in the US health system, limited access to care without cost barriers, and relatively few healthcare personnel and hospital beds per capita. Also, deficiencies in local capacities and capabilities could undermine national readiness.

When developing the 2021 iteration of the GHS Index, researchers took into account information and thinking about what had mattered most during the response to COVID-19. The result was the inclusion of additional socio-demographic, political, and governance variables; a revised Index with 171 rather than 140 items.

The revised GHS Index 2021

In the 2021 GHS Index, 31 questions have been added to address laboratory strength and quality, supply chains, medical stockpiles, isolation and contact tracing capability, national-level policies and plans, and government effectiveness. The researchers recalculated new “2019” scores using the revised Index and information that was available in 2019. This meant that progress from 2019 to 2021 was able to be assessed. It’s important to note that the GHS Index does not give full scores for temporary measures, so COVID-19 responses need to be associated with enduring systems and capacity targeting threats other than COVID-19 to score full marks.

GHS Index 2021 findings

The average country score for 2021 was 38.9 out of a possible 100 points, essentially unchanged from 2019. No country scored above 75.9 and the scores of the bottom 11 nations have all fallen since 2019.[[2]] Despite evidence of growing capacities, there remain major gaps in the capability to leverage these capacities to prevent, detect and respond to emerging biological threats. The US, for example, failed to turn their substantial capacities into a coordinated response to COVID-19. Improvements in response to the COVID-19 pandemic are frequently only temporary, and should be consolidated into robust systems with enduring finance to raise GHS Index scores. Key findings are summarised below.

Findings for 2021 across the six GHS Index categories[[2]]

• Prevention: This was the lowest scoring category in the GHS Index, in particular most countries direct little attention to zoonotic diseases.

• Detection and Reporting: Scores in 2021 reveal major global weaknesses in laboratory systems, laboratory supply chains, real-time surveillance, and reporting.

• Rapid Response: Only 69 countries have a national public health emergency response plan in place addressing multiple communicable diseases. COVID-19 has triggered some gains in non-pharmaceutical interventions planning.

• Health System: There has been little progress in health systems since 2019, with the 2021 Index finding that 91% of countries do not have a plan, programme, or guidelines in place for dispensing medical countermeasures.

• Commitments to Improving National Capacity, Financing, and Global Norms: Just four of 195 countries have identified funding in national budgets, which is dedicated to addressing gaps identified in their World Health Organization (WHO) Joint External Evaluation (JEE).

• Risk Environment: Awareness of risk environment factors, such as orderly transfer of power, social unrest, international tensions, and trust in medical and health advice from the government, is critical because of their large impact on countries’ response to a public health threat.

Additional important findings

• Most countries, including high-income nations, have not made dedicated financial investments in strengthening epidemic or pandemic preparedness.

• Most countries saw little or no improvement in maintaining a robust, capable, and accessible health system for outbreak detection and response.

• Political and security risks have increased in nearly all countries, and those with the fewest resources have the highest risk and greatest preparedness gaps.

• Countries are continuing to neglect the preparedness needs of vulnerable populations, exacerbating the impact of health security emergencies.

• Countries are not prepared to prevent globally catastrophic biological events that could cause damage on a larger scale than COVID-19.

GHS Index 2021 recommendations

The 2021 GHS Index report recommends action by countries, international organisations, the private sector and philanthropic organisations.[[2]] These recommendations are summarised below:

• Countries: Should ensure there are national budgets for building and maintaining health security capacities. The GHS Index and JEE evaluations can support development of National Action Plans for Public Health Security (NAPHS). There should be comprehensive after-action COVID-19 pandemic reports.

• The United Nations (UN), WHO and World Bank: Should use the GHS Index to identify major weaknesses and where urgent support is needed.

• Private Sector: Should use the GHS Index to partner with government to address gaps as well as increase sustainable development and health security R&D portfolios.

New Zealand and the Pacific

In the 2021 GHS Index, New Zealand scores 62.5/100, which is a rise of approximately 10% over 2019 scores, and New Zealand has risen to 13th globally (from 35th). This increase is driven in part by New Zealand’s completion of its JEE, and in part by positive developments in health security as part of the COVID-19 response. We caution, however, about too much focus on rankings, and emphasise that the function of the GHS Index is not necessarily to compare countries that may have quite different political or economic parameters, but rather to guide individual countries in assessments and investments in their own capacities.

Where previously we had lamented New Zealand’s relatively poor showing in the 2019 GHS Index[[3]] (including prior to the COVID-19 pandemic[[16]]), the 2021 report specifically highlights the country as “a case study in progress” (p.44). Stating that, “Country leaders cited preparedness assessments, specifically the GHS Index, as providing the roadmap and impetus for their exemplary performance during the Covid-19 pandemic.” This progress is promising, but the gains need to be consolidated, and persisting weaknesses addressed (see Table 1). The GHS assessment is supported by the observation that the elimination strategy adopted by New Zealand in response to an emerging pandemic (COVID-19) appears optimal, at least during the initial phase when vaccines and antivirals are not available.[[17]]

View Table 1.

We had also previously published our concerns about the generally low GHS Index scores of New Zealand’s Pacific neighbours.[[3]] No one expects that the GHS Index score of a country like Tuvalu will ever approach that of the US, but with scores in 2019 of around 20 out of 100, many Pacific nations were found to lack fundamental components of health security.

In the 2021 GHS Index, of 22 States scoring below 25/100, eight are island nations and six of these are in the Pacific. Nauru on 18.0 scored the least of the island nations and its score fell since 2019.

The relatively successful response of border closure has provided protection to some Pacific islands from the COVID-19 pandemic—and has given time for vaccination levels to rise. However, border closures cannot be indefinite, and cannot protect islands from a threat that originates within borders. Investment in key aspects of Pacific health security is therefore an ongoing requirement.

Focus on global catastrophic biological risks

The GHS Index report continues to have a focus on biological risks of unprecedented scale, that could have devastating outcomes for the world.[[2]] These global catastrophic biological risks (GCBRs) could be orders of magnitude worse than the COVID-19 pandemic. The probability of such events is almost certainly rising due to increasing urbanisation and human expansion, declining biodiversity and a changing climate, upticks in travel, trade, and terrorism, and the use of advanced biotechnologies in the absence of strong, normative guidance on responsible science.[[18]]

The authors of the GHS Index support the formation of an international body to promote early identification and reduction of GCBRs. The Index itself includes consideration of countries’ readiness for GCBRs through 21 sub-indicators, on which the mean global score is only 29.6 out of 100 (see Figure 4). The New Zealand Government may wish to pay particular attention to GCBRs—given that the country is an island,[[19,20]] and because it scores highly as one of the most favourable ones to survive a pandemic with existential risk potential.[[21,22]]

Figure 4: Global scores on 21 GHS Index items relevant to preparedness for global catastrophic biological risks (GCBRs), with New Zealand in the “East Asia and Pacific” grouping.

Source: Nuclear Threat Initiative 2021 (Creative Commons).[[2]]

Opportunities in New Zealand

New Zealand has the opportunity to focus its continuing large investment in its COVID-19 response on creating legacy benefits that will improve its health security.[[23]] Unfortunately, current indications are not promising that it will do this. The recently introduced Pae Ora (Healthy Futures) Bill that sets out a major new structure and arrangements for the health system contained very few specific measures to enhance health security.[[24]] In particular, it fails to specify the kind of independent public health agency needed to reduce the long-term erosion and fragmentation of public health capacity and capability.

Nevertheless, a large funding commitment to the proposed Public Health Agency within New Zealand’s Ministry of Health would be a potentially useful step, with a part of this devoted to improving capacity where the GHS Index benchmarks New Zealand as poorly prepared. As a starting point, the items we identify in Table 1 could be addressed. One example is ongoing disease surveillance. Such surveillance for COVID-19 in New Zealand continues to be suboptimal when compared for example to the UK’s Office for National Statistics Covid-19 infection survey, although the latter has also now been scaled back.[[25]] Similarly, New Zealand needs to keep funding its successful genomic sequencing capacity (as used with COVID-19[[26]]) and its detection of pathogens in wastewater (as also successfully used with COVID-19[[27]]). Wastewater surveillance for pathogens could even be extended to incoming international aircraft—as evaluated in an Australian setting.[[28]] It is programmes such as these, and for the prevention, detection and response to future infectious disease threats that are needed.

The new Māori Health Authority is a positive component of the current health reforms, and it could provide an equity lens to health security enhancements. In particular, it could review the experience of the COVID-19 pandemic from a Māori health and wellbeing perspective, and put this in context with how past pandemics have differentially impacted Māori.[[29]]

Conclusions

The 2021 iteration of the GHS Index provides an updated picture of global health security, with additional emphasis on aspects important through the COVID-19 pandemic. The key finding, again, is that the world remains grossly unprepared for emerging biological threats. That said, there are pockets of improvement, and New Zealand is specifically identified as a country that has bolstered its health security capacity during the pandemic. However, at 62.5/100 there is clearly much more that New Zealand can do to secure protection from future health disaster.

The report emphasises the distinction between capacity and capability. Capacity alone is not enough. Capacities must be exercised and integrated, and governance must be able to ensure they are leveraged when needed. This is capability. Without regular assessments of capacities and capabilities, governments cannot know their levels of preparedness.

A great opportunity exists to develop new capacities and make existing ones more durable, ensuring long-term gains in pandemic preparedness. The GHS Index helps identify important gaps, but, given the course of the COVID-19 pandemic, we may also need assessments that monitor the actual performance of health systems against emerging infectious diseases.

Summary

Abstract

The 2021 Global Health Security (GHS) Index Report was published on 8 December 2021. With an average country score of 38.9 out of a possible 100 points, global scores are essentially unchanged from 2019. Despite experience with the COVID-19 pandemic, no country is adequately prepared for future biological threats. No country scored above 75.9 and the scores of the bottom 11 States have all fallen since 2019. Aotearoa New Zealand, however, has substantially improved its country score, rising to 13th in the world at 62.5/100. This gain is partly driven by consolidation of capabilities developed and deployed in response to COVID-19. This is promising progress, but a lot more can be done to ensure legacy benefits from the pandemic response, notably through the proposed restructuring of the health system (Pae Ora (Healthy Futures) Bill). In this viewpoint article, we discuss this recent further development of the GHS Index, highlight the global results for 2021, delve into New Zealand’s progress, and discuss what more is needed.

Aim

Method

Results

Conclusion

Author Information

Dr Matt Boyd: Research Director, Adapt Research Ltd, Reefton, New Zealand. Prof Michael G Baker: School of Public Health, University of Otago, Wellington, New Zealand. Dr Cassidy Nelson: Future of Humanity Institute, University of Oxford, Oxford, United Kingdom. Prof Nick Wilson: School of Public Health, University of Otago, Wellington, New Zealand.

Acknowledgements

Correspondence

Dr Matt Boyd: Research Director, Adapt Research Ltd, 14 Broadway, Reefton 7830, New Zealand. Ph: +64223512350

Correspondence Email

matt@adaptresearchwriting.com

Competing Interests

Nil.

1) Cameron E, Nuzzo J, Bell J. Global Health Security Index: Building Collective Action and Accountability: Nuclear Threat Initiative and Johns Hopkins Bloomberg School of Public Health. 2019. https://www.ghsindex.org/wp-content/uploads/2019/10/2019-Global-Health-Security-Index.pdf.

2) Bell J, Nuzzo J. Global Health Security Index: Advancing Collective Action and Accountability Amid Global Crisis: Nuclear Threat Institute. 2021. https://www.ghsindex.org/.

3) Boyd M, Baker M, Nelson C, et al. The 2019 Global Health Security Index (GHSI) and its Implications for Pacific Regional Health Security. N Z Med J. 2020;133:83-92.

4) Haider N, Yavlinsky A, Chang YM, et al. The Global Health Security index and Joint External Evaluation score for health preparedness are not correlated with countries' COVID-19 detection response time and mortality outcome. Epidemiol Infect. 2020;148:e210. doi:10.1017/s0950268820002046.

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