Working beyond health: roles of global health security agenda, experiences of Thailand’s chairmanship amidst of the uncertainty of the COVID-19 pandemic

ABSTRACT

The Global Health Security Agenda (GHSA) aims to achieve the vision of a world safe and secure from global health threats posed by infectious diseases through advancing a multi-sectoral approach. Thailand played a prominent role as the Chair of the GHSA Steering Group in 2021, guided by the Chair’s Declaration approved by the Cabinet of Thailand in 2020. In 2021, country efforts were needed to attain the right balance between preparing for future pandemics while responding to COVID-19. This paper details actions and achievements with respect to preparedness and enhancing country’s capacities recommended by the GHSA 2021, which include, among others, garnering high-level support, developing, utilisation of global health security tools, and advocating for sustainable financing. With the continued coordination and collaboration of the Action Packages and translating the Strategic Communications Plan into operation, the GHSA 2024 Target (of measured improvement of health security capacities according to the relevant health security assessments in more than 100 countries) is expected to be achieved by 2024. The unique roles and contributions of the diverse multi-sectoral partners are needed to bridge the gaps and better prepare the world to cope for future pandemics. GHSA not only promotes global preparedness and response, but also complements national preparedness and response. With Thailand’s experience, the GHSA mechanism has been continuously supporting GHSA subnational level activities in border areas. The main outcome of these discussions was the sub-national strategic plan with a multi-sectoral approach to detection, preparation and response.

SUMMARY

1. Public health emergencies highlight the importance of multisector cooperation beyond just the health sector. The Global Health Security Agenda (GHSA) is a global platform that connects different sectors beyond health sectors to enhance health security.

2. Garnering high-level support is necessary to drive forth the GHSA to improve country health securitycapacities. Leadership should be engaged early and often to support resource mobilization and planning & accelerating of implementation activities.

3. As the 2021 GHSA Steering Group Chair, Thailand utilised the GHSA mechanism and efforts to soliciting/facilitating health security efforts at global, regional, and national levels despite the challenges faced during the COVID-19 pandemic.

4. Collaboration &coordination across sectors, strong leadership, and firmed commitments will continue to be important for the GHSA mechanism and the global health security architecture.

KEYWORDS:

• Global health security agenda
• health security
• multi-sectoral approach
• leadership
• GHSA sub-national level

Introduction

The GHSA recognises the importance of high-level political support for multi-sectoral engagement to address gaps in health security capacities. Embedded as a core principle of the GHSA, the emphasis on multi-sectoral approaches aims to build collaboration with partners outside health ministries (i.e. agriculture, food, security, finance, foreign affairs, education, etc.) and the non-governmental sector (Katz et al., 2014). Under the goal of improving global health security capacities, many countries and organisations have sought to align their efforts with the GHSA and by 2022, the number of GHSA member countries/organisations has grown to 77, from around 40 at the initial launch (GHSA Members, 2022). The diversity represented in the membership (country, organisations, and the private sector) geographical locations, economic levels, and sectors affirms the high-level support and inclusivity that is critical in sustaining efforts to prevent, detect, and respond to infectious disease threats.

Thailand joined the GHSA in 2014 and has taken proactive and prominent roles within the GHSA mechanism. Thailand has participated in and led several of the Action Package Working Groups. These Action Packages, such as National Laboratory Systems and Workforce Development, focus on area-specific implementations, convening multi-stakeholder partners in alignment with the GHSA objectives. As the GHSA entered its second 5-year phase as defined under the Kampala Declaration, Thailand accepted a new role to join as a Permanent Member (2019–2024) of the GHSA Steering Group, the governing body that coordinates, communicates and provides direction to the GHSA structure. In November 2020, Thailand virtually hosted the 6th GHSA Ministerial Meeting, with one of the significant outcomes being the Chair’s Declaration (The 6th GHSA Ministerial Report, 2020). The Chair’s Declaration was approved by the Cabinet of Thailand on 17 November 2020, and served as a guiding document in implementing the GHSA efforts during Thailand’s Chairmanship in 2021.

The key elements of the Chair’s Declaration were to build solidarity in preventing and combating the impact of global health threats like the COVID-19 pandemic, similarly addressed in the United Nations General Assembly Resolution 74/270 (2020) and World Health Assembly Resolution 73.1. It emphasised the need for international cooperation to ensure effective and safe global access to medicines, vaccines, and medical devices while calling for alignment in disease preparedness and response policies and operations across government agencies and with non-government partners. Furthermore, the Chair’s Declaration underscored the GHSA objective to identify gaps in health security capacities through relevant health security assessments and frameworks such as the Joint External Evaluation (JEE), International Health Regulations (IHR) 2005 (World Health Oganization, 2017). The Ministerial Meeting also marked the transition for Thailand to assume the leadership role as the 2021 GHSA Steering Group Chair. Thailand’s one-year tenure as the GHSA Chair of the Steering Group was marked by balancing the challenges of COVID-19 while making strides towards the GHSA 2024 target and goal (Global Health Security Agenda GHSA, 2024).

Most countries were confronted with addressing immediate COVID-19 concerns, leaving less time and effort for key personnel to participate in the capacity-building work of the GHSA. Administratively, as international travel was restricted, in-person discussions among the global GHSA governing and area-specific Action Packages could not take place. These limitations occurred during the GHSA chair of the Steering Group led by Thailand. However, as the new coronavirus (SARS-CoV-2) emerged and spread, world leaders strengthened their resolve to combat the outbreak and dialogues on the global health security landscape were elevated. The high-level prioritisation of global health security along with voluntary efforts of individuals working closely with the GHSA mechanism fostered its driving forward.

To enhance the capacities for prevention, detection and response to infectious disease threats, we shared the collective achievements and activities of the GHSA during 2021 based on Thailand’s experience as the GHSA Steering Group Chair and provided recommendations for the remaining duration of the GHSA 2024 Framework.

Galvanising tangible commitments at the highest political levels to achieve provincial, national, regional, and global health security

Garnering high-level support is imperative to promote global health security instruments, make the case for sustained financial backing, foster multi-sector collaboration, and build accountability for GHSA members. During one of the most important global health forums, the 74th World Health Assembly (WHA) in May 2021, Thailand’s Minister of Public Health presented a video intervention emphasising to the high-level delegations, the importance of investing and building in country capacities to prevent, detect and respond to infectious disease threats, underlying that GHSA operates to improve the adherence to the IHR (2005).

The GHSA was also present in other global forums to both raise the visibility of the work of its members and to exchange views with other stakeholders. The first of such events was the aforementioned 6th GHSA Ministerial Meeting, which occurred at the beginning of Thailand’s tenure as Steering Group Chair in November 2020. In combination with the 16 area-specific side events, the 6th Ministerial Meeting was attended virtually by about 1,000 participants from over 80 countries. The Ministerial Meeting (The 6th GHSA Ministerial Report, 2020) was attended by distinguished delegates from GHSA contributing members, the private sector, key development partners, and non – GHSA countries. Along with speeches from the high-level delegates of GHSA countries and member organisations (such as the Global Health Security Agenda Consortium, the Private Sector Roundtable, and the World Bank Group), each of the GHSA’s Permanent Advisors (FAO, OIE (currently WOAH), and WHO) delivered featured remarks from their respective high-level leadership. In addition, there were 10 GHSA countries whose ministers delivered pre-recorded video presentations. These leaders used this forum as an opportunity to underscore the importance of preparedness, increasing financial engagement, and utilising the whole-of-society approach to rapidly mobilise stakeholders’ efforts and resources for urgent matters such as vaccine development. The outcome document of the 6th GHSA Ministerial Meeting, the Chair’s Declaration, further highlighted the importance of high-level engagement and leadership, especially pertaining to sustained financial preparedness.

During Thailand’s one-year tenure as Chair, various GHSA members represented the GHSA in forums such as the G7 Africa Roundtable Health and Development Working Group (represented by Senegal), the G20 Health Working Group Meeting, the Asia-Europe Foundation Roundtable on the Pandemic and the Economy (represented by the Sustainable Financing for Preparedness Action Package), and the 6th virtual meeting of the ASEAN Veterinary Epidemiology Group (AVEG) (represented by the Workforce Development Action Package) (ASEAN Strategy for Exotic, 2021).

The panellists in these discussions echoed the strategic objectives of the GHSA by addressing important issues such as financial preparedness, global and regional approaches, governance, and working towards the GHSA 2024 Target during the COVID-19 pandemic. Another marker of the GHSA’s impact on the global health security landscape is its membership, which reflects solidarity and willingness to participate in this multilateral initiative. For countries and organisations seeking to optimise the benefits of GHSA, their leadership and the GHSA Steering Group must first endorse their membership. Extending the GHSA membership required presenting the added value of becoming a member (Global Health Security Agenda GHSA, 2024). The GHSA Task Force on Advocacy and Communications thus developed the ‘Why GHSA’ infographic to be used in the outreach efforts to prospective members (Figure 1). Thailand presented a path forward for GHSA membership expansion in 2021 using the concept of Friends for Friends (FFF or 3F), calling upon the Steering Group to utilise existing networks to reach out to neighbouring countries and partner organisations to share the ‘Why GHSA’ infographic and explore interest in potential GHSA membership. These efforts in addition to the existing motivation of countries and members to join, yielded the new membership of the Gambia (GHSA Members, 2022), the Caribbean Public Health Agency (CARPHA) (CARICOM TODAY, 2021), Asia-Europe Foundation (ASEF) (ASEF Public Health Network, 2021), Southeast Asia One Health University Network (SEAOHUN) (SEAOHUN, 2021), and the Mekong Basin Disease Surveillance Foundation (MBDS) (MBDS newsletters, 2021), which were all endorsed at GHSA Steering Group meetings throughout 2021. With a membership exceeding 70 members and as several more countries have submitted expressions of interest in 2022, the growth is an indication of the added diversity to the GHSA community and of the strengthening resolve to build core country capacities.

Figure 1. Why GHSA: Benefits of GHSA Membership.

An infographic that lists four benefits of joining the Global Health Security Agenda. The infographic contains a map of the world that allows viewers to visualize which countries are members of the GHSA.

The Steering Group provided inputs to constructively support the GHSA objectives. The structure of the GHSA 2024 Steering Group was composed of 10 Permanent Members (5-year term), seven Rotating Members (2-year term), and three Permanent Advisors (FAO, OIE (currently WOAH, and WHO) (Global Health Security Agenda GHSA, 2024). Similar to the growth of the overall GHSA membership, the Steering Group welcomed three new countries and renewed the terms of all of the Rotating Members. The growth of the Steering Group further affirmed the commitment of countries and organisations (diverse in terms of geography, economic development, and expertise) to assume leadership roles in the global health security ecosystem (Figure 2).

Figure 2. The structure of the GHSA 2024 steering group in 2022.

A map of the world that allows viewers to visualize the regional distribution of 17 GHSA Steering Group Member countries along with the representation of international organizations. Countries are color-coded (red, blue, and green) to differentiate their status as Permanent Steering Group Members, Rotating Steering Group Members, and new Rotating Steering Group Members.

Promoting the development and implementation of tools set by the relevant international organizations and mechanisms to achieve commitments at the country-level, as well as international-level

Identifying gaps is the first step for countries to improve their health security capacities and the capacities of their neighbouring countries. Multilateral platforms and standardised tools allow for the identification of these gaps so that countries can prioritise commitments to making improvements. At its core, the GHSA seeks to enhance global health security by improving compliance with existing frameworks like the IHR (2005). Health security assessments like the JEE further enable preparedness and planning for future threats. In 2020, Thailand, and other countries, underwent assessments of their national COVID-19 responses by conducting intra-action reviews (IAR) under the guidance of the WHO (WHO, 2022). The review process allows countries to critically reflect and receive feedback while being able to identify priority areas for improvement to guide activities in the short, medium, and long term. During Thailand’s tenure as GHSA Steering Group Chair, the GHSA Secretariat, which consisted of Indonesia, Pakistan, and Thailand, saw alignment with the whole-of-government approach, direction of the GHSA 2024 Framework, and the IAR. Following communication with the WHO IAR team, the GHSA Secretariat used the GHSA mechanism (quarterly newsletter and GHSA website) to encourage GHSA members to conduct their own IARs.

The work of the Tripartite, especially in regard to the One Health approach, has been synergistic with global preparation and response efforts. The Tripartite members continuously provided technical support to GHSA Action Packages and direction to the Steering Group (Steering Group Secretariat et al., 2015), consistent with the Chair’s Declaration. The GHSA platform exhibited the flexibility to serve as a hub for sharing resources and best practices, being able to promote practical tools for countries to use, such as the joint Tripartite Zoonoses Guide. Under the National Laboratory Systems Action Package, Thailand also promotes the ‘networking of the networks’ to bridge the GHSA efforts within and among the regions.

The implementing arms under the GHSA mechanism also offer flexibility aimed at countries to improve their global health security capacities. In 2021, the GHSA Steering Group launched the GHSA Commitment Visualization tool as an opportunity for GHSA members to share commitments to global health security on the GHSA website. To encourage GHSA members to submit commitments, a ‘call to action’ was signed by Thailand’s Minister of Public Health for distribution to all GHSA members. To further improve visibility and showcase best practices, the GHSA Secretariat collected and shared ‘Stories of Impact’ from GHSA members that illustrate how the country or organisation’s actions led to a concrete improvement.

In recognition of the importance of research and development (R&D) in health security preparedness, the fact that R&D was not directly addressed in key global coordination mechanisms and frameworks, and inequalities in access to vaccines, therapeutics, diagnostic tools, and other potentially life-saving tools between high and low-income countries, the Global Health Technologies Coalition (GHTC) led the establishment of the GHSA Task Force on R&D (GHSA Research & Development, 2021). This Task Force convened the GHSA members and stakeholders meetings to explore how R&D of medical countermeasures factors into national and regional health preparedness plans. The Task Force is developing a roadmap of metrics for country R&D capacities. The R&D Task Force is cross-cutting in nature; therefore, it can coordinate with relevant GHSA Action Packages to address gaps.

More efforts to address gaps in the global health security landscape were made in 2021, with the establishment of the Legal Preparedness Action Package. Noting the lack of attention towards strong systems of legal preparedness for health emergencies, the Action Package aims to facilitate improving decision-making processes and operations before, during, and after the pandemic. Under the leadership of Argentina, Georgetown University Law Center’s O’Neill Institute for National and Global Health Law, and the United States, it supports the enhancement of countries’ legal preparedness capacities through gathering experts and developing technical tools for countries to apply.

Promoting and supporting the mobilisation of funds to achieve financial sustainability for health security capacities

Improving national global health security capacities, countries must sustain financial support, which requires the ability to justify the benefits and present the added value of such financial support. The work of the Sustainable Financial Preparedness Action Package (SFPAP) aligns with the efforts of securing resources to fill the gaps. As mentioned previously, the SFPAP participated and intervened at global forums such as the Global Health Summit and the ASEF webinar on the pandemic and economy to share the economic case for country investment in global health security systems.

To present the value added to the efforts made by the GHSA members, the GHSA Task Force on Accountability and Results shared the findings of their analysis of the progress towards the GHSA 2024 Target and has made them publicly available on the GHSA website. The results of the analysis showed an increase in the number of countries reaching the 2024 Target over time as well as a greater improvement of average scores in the relevant technical areas (GHSA progress to target, 2021). By conveying that progress is achievable, it also builds upon the momentum of the SFPAP to motivate high-level leaders to secure and sustain financial support for global health security capacities.

Not only did the GHSA promote global preparedness and response, but it also complemented the country’s preparedness and response with the experience of Thailand

In Thailand, the National International Health Regulations (IHR) Committee is composed of 18 ministries. Under the National IHR Committee mechanism is the Sub-national GHSA Committee, which is composed of four ministries. Throughout the COVID-19 pandemic, Thailand has been reminded repeatedly that disease transmission occurred despite the presence of national borders and the impact of COVID-19 caused massive changes to the public health system. The Thai Ministry of Public Health has used the Sub-national GHSA Committee in accordance with IHR as an opportunity to rethink and adjust Thailand’s national health system to ensure better preparation and response to the next pandemic and the subsequent challenges and crises.

Thailand’s effective responses to the COVID-19 pandemic should be credited to the proactive efforts of public health leaders and international development partners in health workforce development, especially through the Field Epidemiology Training Program (FETP). The program has been active in Thailand for over 40 years and has produced a large health workforce of field epidemiologists under the national health system. The Thai Ministry of Public Health fully acknowledges the importance of maximising the capacity of field epidemiologists. At the same time, Thailand implements measures that promote career advancement and provide fair and equitable revenue for the various health workforce roles at all levels. These measures are aimed to attract new graduates into the public health system, requiring careful monitoring and timely adjustment to ensure the sustainability and capability of the national health system. However, capacity building with only epidemiologists in prioritising workforce development is not adequate to address health threats. The strategic workforce development plan must take into account the laboratory, animal, environmental, and wildlife health and private sectors. This proposal was proposed to the GHSA Sub-national Committee and the Committee from relevant sectors agreed to increase staff and officials in order to have more engagement in the FETP.

Another example of adopting a multi-sectoral approach at the national level under the core principles of the GHSA was in March 2021, when the secretariat team of the Sub-National GHSA Committee collaborated with national and international networks to prepare to use the avian influenza Joint Risk Assessment (JRA) tool developed by the Tripartite, Food and Agriculture Organization of the United Nations (FAO), World Organization for Animal Health (WOAH), and the World Health Organization (WHO). Thailand continues to be at risk of an outbreak of avian flu, especially in border areas due to the movement and export of poultry across borders and the risk of infection among persons working with poultry, such as poultry farmers and traders. The JRA workshop gathered over 60 participants from the Ministry of Health, the Ministry of Agriculture and Cooperatives, the Ministry of Natural Resources and Environment, academia, the Tripartite, international organisations agencies such as USAID and U.S. CDC, as well as the Thailand GHSA Coordinating Unit and Thailand One Health Coordinating Unit. The JRA tool has assisted in identifying and managing the risks of avian influenza and has helped address operational gaps and strengthen the collaboration among human, animal and environmental health agencies under the One Health concept.

To apply the GHSA mechanism from the global level to the local level, the Department of Disease Control, Ministry of Public Health, Thailand has continuously supported the activities of the GHSA sub-national level in border areas since 2020. The central level provided the concept of GHSA to targeted areas along the border provinces and asked local agents to identify challenges in detection, prevention and response to health threats. Thereafter, the central level has assisted the local level in coordinating across sectors and ministries to facilitate working group discussions. The main outcome of these discussions was the sub-national strategic plan with a multi-sectoral approach on detection, preparedness and response. Some of the proposed activities raised by the provincial level relate to strengthening risk communication capacity and integration of non-health sectors with Public Health Emergency Operations Centers (PHEOCs) to manage future crises.

Recommendations

Maintaining strong coordination in the GHSA’s governance structure is a key factor in strengthening national capacities and for continued progress towards prevention, detection, and response to infectious disease threats.

1. Engagement with existing GHSA members

Through communication with the GHSA Secretariat, current members need to confirm and ensure their focal points are up to date. GHSA members are encouraged to submit high-level Commitments and Stories of Impact for display on the GHSA website (https://globalhealthsecurityagenda.org/campaigns/) to share accomplishments and intentions.

2. Continuing coordination of the action packages

Enhancing and fostering working across the Action Packages is crucial. The Task Force on Action Package Coordination has already highlighted the importance of how the members including the GHSA Chair and Secretariat could support the Action Packages, particularly outreach activities. The progress of each Action Package should be updated regularly with the GHSA membership as well. The Task Force on Action Package Coordination should continue its identification of gaps and challenges to increase collaboration between Action Packages and encourage the One Health approach. Moreover, the functionality of Action Packages should be promoted in countries and identify ‘non-traditional’ partners to join Action Packages. In addition, the work of the new Action Package on Legal Preparedness should be promoted for countries to consider joining to enhance emergency preparedness.

3. Implement the strategic communications plan into practice

The GHSA Strategic Communications Plan was endorsed by the Steering Group in 2021 and provides direction on how to promote broad awareness of global health security goals with guidance on internal and external communication. The objective of the Strategic Communications Plan includes sharing the benefits of GHSA, convincing the public of the need for investment in preparedness, urging governments to provide financing for preparedness, building collaborations beyond the human health sector to maximise funding sources, and presenting concrete commitments from GHSA members. These objectives form the basis for annual action plans to be developed by GHSA Steering Group members, the Chair and the Secretariat. One important matter in the document is the designated GHSA formal spokesperson, who can amplify the GHSA’s critical roles and messages to broader audiences. The selection criteria for the GHSA spokesperson is important and there is a need for further discussion on how to proceed. A trial on the roles and responsibilities of the GHSA spokesperson should be implemented and should be assessed after one year.

4. Continued support to strengthen the GHSA Secretariat’s tasks

The GHSA Secretariat has shown a key function in various tasks including the overall coordination and the GHSA website management. However, more support from the countries, the GHSA members, as well as other partners, will be valuable in moving the GHSA forward to achieve its target and goal.

Conclusions

As COVID-19 elevated the attention and importance of global health security preparedness, the pandemic created obstacles that hindered the ability to organise global discussions on these issues. With respect to the GHSA achievements made in 2021 during Thailand’s tenure as Chair, it is a testament that high-level support and individual motivation maintain a strong presence in improving the global health security landscape. One of the strengths of GHSA is bringing together partners in a voluntary manner. The contributions of diverse multi-sectoral partners, including the private sector, can provide essential solutions to close gaps in pandemic preparedness. Preparedness, detection, and responses are critical in making the world safe and secure from infectious disease threats. The ‘whole-of-government’ and ‘whole-of-society’ approaches need to be embraced and encompass civil society, the private sector, academic institutions, and a wide range of government sectors.

Ethics statements

Not applicable for patient consent for publication.

Acknowledgments

We thank Dr. Karoon Chanachai, USAID Regional Development Mission Asia for his valuable advice as an external advisor of the Thailand GHSA Coordinating Unit. Thank you to Dr. Tanarak Plipat, Ministry of Public Health, Thailand for his pioneering vision of GHSA activities in Thailand. Thank you to Dr. Sopon Iamsirithaworn, Department of Disease Control, and High Level Executives of the Ministry of Public Health’s Departments (Department of Disease Control, Department of Medical Sciences, and Thai Food and Drug Administration) for policy support to drive GHSA forward in Thailand. We also thank all members of the National GHSA Sub-committee in Thailand from various ministries and development partners for all of their contributions. Lastly, we would like to thank colleagues from the Department of Medical Sciences, Division of Epidemiology and Office of International Cooperation, the Department of Disease Control, Ministry of Public Health, Thailand for their kind support and professional implementation to enhance global health security. We thank the Steering Group, the GHSA Secretariat and GHSA members for providing valuable information, supporting and sharing opinions for a sustainable GHSA network. Open Access funding provided by the Qatar National Library.

Disclosure statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Data availability statement

Data sharing is not applicable as no datasets were generated and/or analysed for this study.

Additional information

Notes on contributors

Soawapak Hinjoy

Soawapak Hinjoy was head of the GHSA coordination unit in Thailand to develop effective public health prevention and control strategies from a global health security perspective.

Royce Tsukayama

Royce Tsukayama was a project coordinator of the GHSA coordination unit in Thailand and coordinated other members of the GHSA.

Jintana Sriwongsa

Jintana Sriwongsa was an advisor to the GHSA coordination unit in Thailand to provide strategic direction from a global health security perspective.

Darika Kingnate

Darika Kingnate was an advisor to the GHSA coordination unit in Thailand to provide strategic direction from a global health security perspective.

Sudarat Damrongwatanapokin

Sudarat Damrongwatanapokin was an advisor to the GHSA coordination unit in Thailand to provide strategic direction from a global health security perspective.

Wattana Masunglong

Wattana Masunglong was a technical staff member of the GHSA coordination unit in Thailand to develop effective public health prevention and control strategies from a global health security perspective.

Pitchapa Kleeblumjeak

Pitchapa Kleeblumjeak was a technical staff member of the GHSA coordination unit in Thailand to develop effective public health prevention and control strategies from a global health security perspective.

Walaiporn Jiaranairungroj

Walaiporn Jiaranairungroj was a project coordinator of the GHSA coordination unit in Thailand and coordinated related organizations at the local level.

Khanchit Limpakarnjanarat

Khanchit Limpakarnjanarat was head of advisors to the GHSA coordination unit in Thailand to provide strategic direction from a global health security perspective.

Sura Wisedsak

Sura Wisedsak was a high-level executive to develop effective public health prevention and control strategies from a global health security perspective.