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Emerging Priorities for Public Health Emergency Preparedness

In January 2020, when COVID-19 was still a ‘Pneumonia of unknown aetiology’ in Wuhan, China, Nigeria was battling an outbreak of Lassa Fever threatening to spiral out of control. A lot was being done in response to this outbreak — including rodent studies, bilateral engagement with the Republic of Benin (with whom there’s been a history of cross-border transmission), risk communication campaigns, National and State EOCs set-ups. All these went unnoticed by the public for the most part. Nigeria had faced similar outbreaks in the past and responded more or less successfully without requiring the kind of ‘whole-of-government’ response we have seen with COVID-19. In contrast, every decision taken in response to COVID-19 is now under scrutiny by both the public and political leadership.

A key implication of this ‘whole-of-government’ ‘whole-of-society’ response paradigm to a pandemic is that science began to take the back seat in how decisions were being made — this was, of course, not a uniquely Nigerian problem. The reason this approach has more or less thrown the world a curve is that in our preparedness Plans for Pandemics we assumed decision making and coordination will follow the same patterns as for other limited public Health Emergencies. Or we thought, as I was told at a recent preparedness plan writing workshop, it was outside the scope of public health emergency management teams to design how ‘whole-of-government’ coordination and responses should work.

Contingency Planning must make Coordination and Response prescriptions for all kinds of public health events — from the ‘routine/at-all-times’ measures, to what to do with ‘PHEICs’, and finally how to manage ‘Pandemics’ or order of public health emergencies requiring ‘whole-of-government’ response.

This is the first of eight priorities for public health emergency preparedness for Businesses and Governments. Below, I will briefly outline seven other priority considerations in revising public health emergency preparedness plans and protocols in order to be more resilient as we emerge from this Pandemic.

Contingency plans are a type of coordination mechanism and are ineffective without connecting with other coordination mechanisms

A common blindspot in contingency planning is being unable to situate the Plan in the context and ecosystem in which it must operate. Contingency plans for public health emergencies exist in an ecosystem of other multi-level (and often multi-hazard) preparedness plans and coordination mechanisms. For instance, it is critical that a large multi-terminal POE with private operators have both terminal-specific and POE-wide integration and coordination platforms. These platforms then need to also integrate with the state/provincial ‘plans’, which in turn should be linked to the national ‘plan’. In addition to these, there are also industry-specific national and international plans with which integration is essential. The capacity to ‘integrate’ these Plans and mechanisms and operationalise them is important and necessary expertise. It is also as rare as it is crucial.

To do this, facilitators of this integration should combine the development (or revision) of a comprehensive Public health contingency plan with the development of the capacity to both operationalize and integrate with other system-wide/national plans and coordination mechanisms. This process is heavy in stakeholder mapping and engagement and initial results often seem indistinguishable from the methods.

Businesses and Governments must pursue a Multi-Hazard and One-health Emergency Preparedness approach

Epidemic prone infectious diseases with person-to-person transmission are not the only public health threat that governments and businesses should plan for. Infectious diseases also have a significant animal and environmental component. In addition to this, chemical events and other threats related to the highly sensitive cargo that may pass through (or stored at) seaports and airports pose a significant threat. Plans must be savvy enough to address human, animal and environmental or other related threats — regardless of where they are situated in the ecosystem of plans. This means the emergency response approach to all emergencies affecting human health must be integrated into a single public health ‘coordination mechanism’ (at each level of coordination) that also leverages and is integrated with other system-wide emergency response plans. We shouldn’t have to wait till we have an atypical emergency before we ‘bring in’ the X hazard expert, a la the movies.

Forward-leaning postures that don’t reach beyond first and second-order consequences will not suffice

One of the most significant constraints of contingency planning is an inability to imagine all the probable, plausible and possible futures beyond first-order consequences. Public health contingency planners often believe that their role in imagining events and emergencies and consequences end with the specific threats facing us today. Traditional contingency planning methods rarely solve for risks beyond the effects of first-order events. Businesses and governments should seek an approach (with the design futures a perfect match) that not only speculatively imagines all threats faced in the industry (and backcasts for mitigation approaches) but also threads all possible second and third-order consequences of mitigation and response measures resulting in a highly agile, responsive, forward-leaning and future-facing contingency plan. Design Futures props us in a perfectly-balanced, appropriately primed forward-leaning posture.

Simulation Exercises are the lifeblood of preparedness plans and protocols but only true when the exercises are done well and often

The key to making ‘plans’ context savvy and agile is constant exercises and reviews based on the response to exercises. These can range from tabletop exercises to operation-based SIMEXs. In designing simulation exercises we need to be strategic in our approach to imagining scenarios. Failure to imagine (and create triggers) for the second-order effects of mitigation measures deployed is one of the central weaknesses of a significant number of exercises done before COVID-19. I have written elsewhere some of my thoughts on SIMEX.

Contingency Plan Development should be co-created and user-driven

A dedicated team using a user design process that leans heavily on the expertise of the key operators and personnel to design and develop a flexible Public Health Emergency Contingency plan is critical to the process. Depending on the complexity of the facility, state/province or POE, this may take between 4 and 20 development sessions. Each session will be an iterative and co-creative session between the facilitation team and the facility personnel. Where facilities have an existing ERP for public health events, this can be reviewed to incorporate the key lessons from the current pandemic and a reappraisal of facility context using design futures thinking. While developing the PHECP, the co-creation method will allow for the identification of improvements to existing protocols and novel areas for which standardised procedures need to be laid out.

Operators need to be trained on how to use Plans and protocols

Training and or workshop sessions on the operationalisation of the Plan, integration with other coordination Mechanisms etc. should be conducted for staff and management of the facilities and health and safety departments. The first time I designed a training curriculum for a contingency plan, it was done as a band-aid. But we soon realized that plans work so much better when people are familiar with both the measures proposed and the rationales behind them. Every plan should have a regular training/workshopping schedule built for it in addition to exercises.

Risk Assessment needs to be threat and measures-specific

A thorough risk assessment of the facilities/processes/communities/etc. within the coverage area for the contingency Plan and the facilitation of processes within those areas will need to be done. In some cases, tools already exist for these assessments so we are tempted to just reach out for them. Given what we have learned over the past few months, it is important to adapt or draw up new assessment tools that are threat-specific (and facility and process-specific as well) and that assesses the capacity to both deploy measures sustainably and mitigate adverse second-order effects of measures deployed.

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