Multisectoral
preparedness
coordination
framework

Best practices, case studies
and key elements ofadvancing multisectoral
coordination for healthemergency preparedness
and health securityMultisectoral preparedness
coordination framework
Best practices, case studies and key elements of advancing multisectoral
coordination for health emergency preparedness and health security

Multisectoral Preparedness Coordination Framework: best practices, case studies and key elements of advancing multisectoral
coordination for health emergency preparedness and health security
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Key elements of multisectoral preparedness coordination

Contents
Acknowledgements
Executive summary
1
Purpose of document
1.1
Scope
1.2
Objectives
1.3
Target audience

iv
v
1
1
1
1

2
2.1
2.2
2.3
2.4

Introduction
BackgroundDefinitions, related initiatives and technical documents
Need to address gaps in multisectoral preparedness coordination
Stakeholders relevant for health emergency preparedness and health security

1
1
2
4
5

3
3.1
3.1.1.
3.1.2.
3.2
3.2.1.
3.2.2.
3.2.3.
3.2.4.
3.3
3.3.1.
3.3.2.
3.3.3.
3.3.4.

Key elements of multisectoral preparedness coordination
High-level political commitment
Country ownershipChampions and leadership
Formalizing multisectoral preparedness coordination
Developing multisectoral coordination structures
Stakeholder mapping and analysis
Joint needs assessment
Formalizing the multisectoral preparedness coordination
Implementing multisectoral preparedness coordination
Transparency, trust and accountability
Communication
Health security preparedness funding
Monitoring the multisectoral preparedness coordination

8
8
8
8
9
9
10
11
11
12
12
12
13
14

References
Annex 1: Literature Review
Annex 2:	Expert roundtable: development of a guide for multisectoral preparedness
coordination for IHR (2005)
Annex 3: Tripartite zoonoses guide and health emergency and disaster risk
management framework
Annex 4: Examples of regional and international initiatives supporting multisectoral
preparedness coordination

15
19
30
31
33

iii

iv

Multisectoral preparedness coordination framework

Acknowledgements
The World Health Organization (WHO) would
like to express sincere gratitude to all countries,
WHO regional offices, WHO country offices andpartners who contributed to the developmentof this Multisectoral preparedness coordination
framework: best practices, case studies andkey elements of advancing multisectoral
coordination for health emergency preparedness
and health security.
The document was prepared and finalized by theMultisectoral Engagement for Health Security Unit,
led by Ludy Suryantoro, Unit Lead, and Romina
Stelter, Technical Officer, with the support of Stella
Chungong, Director, Health Security Preparedness
Department, and Jaouad Mahjour, Assistant
Director-General, Emergency Preparedness andInternational Health Regulations.

WHO thanks the World Organisation for
Animal Health and the Food and Agriculture
Organization of the United Nations for theprovision of technical and financial assistanceduring the process.
WHO is grateful to the following countries fortheir valuable input during an expert meetingin Paris, France, in October 2018: Bangladesh,
Canada, Finland, France, Germany, Ghana,Indonesia, Jordan, Nigeria, Romania, Thailand,
Tunisia, United Kingdom of Great Britain andNorthern Ireland, United Republic of Tanzania,
United States of America, Viet Nam and Zambia.
Special thanks also go to the following for their
input: Jonathan Abrahams, Sean Cockerham,
Marcus Eder, Kaylee Errecaborde, Andreas
Gilsdorf, Marc Ho, Nirmal Kandel, Daniel Lins
Menucci, Peter Mala, Elizabeth Mumford, Abbas
Omaar, Rajesh Sreedharan and Nicole Valentine.

Key elements of multisectoral preparedness coordination

Executive summary
Countries must be better prepared to detect
and respond to public health threats in orderto prevent public health emergencies and thedevastating impact they can have on people’s
lives and well-being, as well as on travel andtrade, national economies and society as a whole.
Public health challenges are complex and cannot
be effectively addressed by one sector alone.
A holistic, multisectoral and multidisciplinary
approach is needed for addressing gaps andadvancing coordination for health emergency
preparedness and health security, and is essential
for the implementation of the International
Health Regulations (2005).
This document provides States Parties, ministries,
and relevant sectors and stakeholders with an
overview of the key elements for overarching, allhazard, multisectoral coordination for emergency
preparedness and health security, informed bybest practices, country case studies and technicalinput from an expert group. Those elements
form the basis of a multisectoral preparedness
coordination framework that will aim to improvecoordination among relevant public stakeholders,
particularly actors beyond the traditional healthsector, such as finance, foreign affairs, interior
and defence ministries, national parliaments,

non-State actors, and the private sector,
including travel, trade, transport and tourism.
The framework outlined in this documentcomplements the International HealthRegulations Monitoring and Evaluation
Framework and contributes to the strategic goalin the WHO Thirteenth General Programme ofWork of 1 billion more people better protectedfrom health emergencies, and supports theachievement of Sustainable Development Goal
3 – ensure healthy lives and promote well-being
for all at all ages. The document discusses key
elements for effective multisectoral coordination
for health emergency preparedness, including
high-level political commitment, country
ownership and leadership, and formalizing
mechanisms that contribute to multisectoral
preparedness coordination. Transparency, trust,accountability, communication and resources will
be required for the proper functioning of suchmechanisms. Monitoring needs to be intrinsic
to the process in order to measure progress in
implementing the framework. Context-specificpriorities should be considered in developing
mechanisms that reflect the different needs
and contributions of the relevant stakeholders
in order to ensure effective, synergetic
multisectoral coordination for health emergency
preparedness and health security.

vvi

Multisectoral preparedness coordination framework

Key elements of multisectoral preparedness coordination

1

Purpose of document

1.1

Scope

Countries must be better prepared to prevent,detect and respond to public health threats inorder to prevent public health emergencies andthe devastating impact they can have on people’s
lives and well-being, as well as on travel andtrade, national economies and society as a whole.
Public health challenges are complex and cannot
be effectively addressed by one sector alone.
A holistic, multisectoral approach is needed forappropriately addressing gaps and advancing
coordination for health emergency preparedness
and health security.
High-level political commitment and technicalguidance are both necessary for successful
multisectoral coordination for healthemergency preparedness and health security.
The multisectoral preparedness coordination
framework focuses on engaging high-level policymakers and decision-makers in order to ensure awhole-of-government, whole-of-society approach
to multisectoral preparedness coordination.
To address this necessity, the World HealthOrganization (WHO) has developed the present
document and will bring together, through its
convening role, ministers and high-level decisionmakers from relevant public and private sectors
in a series of forums and meetings, starting with
the High-Level Meeting on Diplomacy for Health
Security and Emergency Preparedness co-hosted
by the Kingdom of Morocco, the Republic of
Rwanda, the World Bank and WHO at the end of2020 in Marrakesh, Morocco.

1.2	Objectives
This document has the following objectives:•	to enhance collaboration and coordination
between the public health sector and allother relevant stakeholders and sectors that
may be engaged in and can contribute toadvancing health emergency preparedness
and health security;•	to provide guidance on critical elements thatcountries may consider in strengthening
multisectoral coordination for healthemergency preparedness and health security;•	to highlight a variety of best practices andcase studies for multisectoral coordination for

health emergency preparedness and healthsecurity, reflecting the need for contextspecific variation for effectiveness1.3	Target audience
This document addresses policy-makers anddecision-makers in the public health sector, as
well as actors in all other relevant sectors thatshould be engaged in advancing multisectoral
coordination for emergency preparedness andhealth security. The framework is intended
to support high-level stakeholders involvedin promoting, engaging in, establishing,strengthening, advancing and monitoring
multisectoral coordination.
While most best practices and case studies
illustrated in this document reflect the national
level, the identified key elements of multisectoral
coordination can also apply to the regionaland global levels. This framework is neitherprescriptive nor does it offer one-size-fits-all
solutions, but rather intends to emphasize theneed for historical, geopolitical and socioeconomic
contextualization. It is also recognized that therequirements for multisectoral engagement infragile and conflict-affected countries and regions
may demand a modified approach.

2

Introduction

2.1

Background

Health emergencies, including disasters, takea heavy toll on populations around the globe(1). Human and animal diseases, chemical,
radiological and nuclear accidents, and natural
disasters cause ill-health, disability, loss of
lives, food insecurity, environmental damage,displacement, and destabilization of trade andeconomic development, as well as of societies
as whole. Diseases can spread, and they can doso even more significantly where health systems
are fragile or are faced with newly emerging
and re-emerging diseases, as seen in recent
outbreaks of Ebola virus disease, Zika virus
disease, yellow fever, cholera and COVID-19,
affecting entire countries and regions. As a result,health security is high on the international agenda(2). International intergovernmental forums
that discuss financial and socioeconomic issues
to coordinate global policy – such as the Groupof Seven (G-7) and Group of Twenty (G-20) –1

2

Multisectoral preparedness coordination framework

emphasize the interlinkages between and support
the integration of health system strengthening,
country emergency preparedness and healthsecurity (3). Health security is a continuous
process in which action, financing, partnerships
and political commitment must be sustained.

countries to better prevent, detect and respondto all potential public health threats.

2.2	Definitions, related initiatives andtechnical documents
WHO defines emergency preparedness as “theknowledge and capacities and organizational
systems developed by governments, response andrecovery organizations, communities and individuals
to effectively anticipate, respond to, and recoverfrom the impact of likely, imminent, emerging, or
current emergencies” (9). Multisectoral preparedness
coordination refers to the deliberate collaboration
between stakeholders from multiple and diverse
sectors and disciplines working towards the sharedgoal of enhanced health emergency preparedness
by leveraging knowledge, expertise, strengths, reachand resources. Successful multisectoral preparedness
coordination is dependent on political, economic
and social factors, and requires commitment from all
stakeholders working together.

The International Health Regulations (IHR)(2005) represent the legal basis for multisectoral
coordination for emergency preparedness andhealth security. WHO promotes the participationof all relevant sectors to contribute to theimprovement of the capacity of States Parties
to prevent, detect and respond to publichealth emergencies of international concern
and accelerate the implementation of the IHR(2005) (4). An intersectoral approach is among
the guiding principles for implementation of
the IHR (2005) set out in a report by the WHO
Secretariat to the Seventieth World Health
Assembly, May 2017, which states: “Responding
to public health security threats requires amultisectoral, coordinated approach (for example
with agriculture, transport, tourism and financesectors)” (5). The IHR (2005) Monitoring and
Evaluation Framework (6) provides operational
tools for countries to identify strengths, gaps
and priorities around health security capacities.
In addition, WHO supports countries in
conducting national bridging workshops tostrengthen collaboration between the animaland human health sectors, and also supports thedevelopment of national action plans for healthsecurity to address country gaps and needs.
WHO, through the Strategic Partnership for IHRand Health Security portal, shares information on
country, partner, and donor initiatives, activities,
and investments to facilitate coordination andharmonization between all relevant stakeholders.

The 1978 Declaration of Alma-Ata (10) stated that“the attainment of the highest possible level ofhealth is a most important world-wide social goal
whose realization requires the action of many othersocial and economic sectors in addition to thehealth sector”. Numerous other publications andresolutions relating to health security have since
recommended a multisectoral approach, including
the Ottawa Charter for Health Promotion, 1986(11), the Framework for Action on health systemstrengthening, 2007 (12), the Health in all Policies
analytic framework (13), United Nations General
Assembly resolution 67/81 on global health andforeign policy, 2012 (14), and World Health Assembly
resolution WHA65.23 on implementation of theInternational Health Regulations (2005), 2012 (15).

Under the WHO Thirteenth General Programmeof Work 2019–2023 (7), the WHO Health
Emergencies Programme has an integral role incontributing to the strategic priority of 1 billion
more people being better protected from healthemergencies by building and sustaining thenational, regional and global capacities required
to keep the world safe from health emergencies.
In support of implementation of the Thirteenth
General Programme of Work and attainment of
Sustainable Development Goal (SDG) 3 (8), thisdocument provides evidence-based information
on how to establish functional multisectoral
coordination, primarily within but importantly
also beyond the government structures, for

Recent technical documents have also called
for improved coordination among sectors,
including the report of the United Nations
Secretary-General to the Seventieth sessionof the United Nations General Assembly on
strengthening the global health architecture,2016 (16); the WHO working paper on tackling
antimicrobial resistance, 2018 (17); the WorldBank operational framework for strengthening
human, animal and environmental public healthsystems at their interface, 2018 (18); the WHO
checklist for pandemic influenza risk and impact
management, 2018 (19); the WHO country
implementation guide for national action planfor health security, 2019 (20); the WHO, Food

Key elements of multisectoral preparedness coordination

and Agriculture Organization of the United Nationsand World Organisation for Animal Health tripartite
guide to addressing zoonotic diseases in countries,
2019 (21); the WHO Health Emergency and Disaster
Risk Management Framework, 2019 (22); and the
Global Platform for Disaster Risk Reduction (23).
Numerous forums, including the second WHO Africa
Health Forum (24), have also called for increasing
multisectoral efforts to increase the capacity ofcountry health systems for achieving health security,community and country resilience, universal healthcoverage and sustainable development.

have acknowledged the need for a multisectoral
approach to strengthen national capacities toprevent, detect and respond to long-standing,emerging and re-emerging infectious diseases aswell as other threats. Partners working in supportof national, regional and global health security
include the tripartite alliance of WHO, the Foodand Agriculture Organization of the United Nations
and the World Organisation for Animal Health (25),other international organizations, developmentbanks, regional organizations, collaboration centres
and nongovernmental organizations.

A wide range of international partners and donors
supports country health emergency preparedness
under various health security initiatives andBox 1 provides an example of multisectoral preparedness coordination from Senegal.

Senegal: a high-level, multisectoral and One Health approach tohealth security
The Prime Minister of Senegal established the One Health National High Council for Global Health Security by decree in2017. The council was created in recognition that multisectoral collaboration, with inclusive involvement of all sectors
and coordination at the highest level of government, was the only way to guarantee success in the implementation of
the IHR (2005). Experiences with rinderpest, HIV/AIDS, avian influenza, and Ebola virus disease had demonstrated
that building strong health security required close collaboration across sectors.
The main mission of the One Health National High Council for Global Health Security is to define the strategicorientations of the global health security programme based on a One Health approach within the framework of
the IHR (2005). Primary objectives are to ensure the synergy and complementarity of the human, animal andenvironmental health sectors to achieve public security, civil security and food security, and to mobilize sustainablefunding for the implementation of the health security strategy.
The council, which meets annually, is chaired by the Prime Minister. Other members include ministerial-level
representatives from relevant sectors (human health, animal health, environment, agriculture, finance, defence,
public security, education, transport and communication).
In carrying out its mission, the council is supported by the following bodies:•	the Steering Committee for Multisectoral Coordination for Global Health Security, comprising representativesof government (Secretary-General, secretaries-general and directors-general of relevant ministries), presidents
of national professional associations (physicians, veterinarians, nurses, environmentalists, pharmacists, wildlife
conservators), the private sector and civil society organizations, which is responsible for adoption, monitoring andcoordinating implementation of the health security annual programme, and meets once a quarter or when necessary;• the permanent Secretariat;•	the Technical Committee for One Health Multisectoral Coordination, which is responsible mainly for drawing up a
consolidated annual multisectoral plan for global health security and ensuring coordination and monitoring of multisectoral
preparedness for and response to any human, animal or environmental health threat with national or international impact;• sectoral committees for multisectoral coordination;•	decentralized committees (local communities) for multisectoral coordination led by the head of the highest authority
in the administrative district, which are responsible for coordinating and leading activities at the local level within theframework of the global health security programme;• the multisectoral thematic groups with respect to the IHR (2005);• the IHR focal point.

3

Multisectoral preparedness coordination framework

2.3	Need to address gaps inmultisectoral preparedness
coordination
Frequently, multisectoral coordination is put inplace only during the response to a public healthemergency, and in most cases is limited to a
specific disease or hazard and to the duration of
the emergency. This was the case for outbreaks ofsevere acute respiratory syndrome (SARS), H5N1
avian influenza and Zika virus disease, as well asother outbreaks and major disasters. For reasons ofeffectiveness and sustainability, it is critical to build
viable coordination before the need to respondto an event arises, driven by a culture of and asystematic approach to emergency preparedness
and the strengthening of health systems.
Data from the 2018 State Party self-assessment
annual reporting (SPAR) (26) questionnaire
highlighted the critical need for improving
coordination among relevant stakeholders acrossthe various IHR capacities. There are four SPAR
indicators that assess capacities specificallyrelated to multisectoral coordination:•	C2.1 National focal point functions under IHR•	C2.2 Multisectoral IHR coordination andmechanisms•	C.3.1 Collaborative effort on activities toaddress zoonoses•	C4.1 Multisectoral collaboration mechanism
for food safety events.

80
70

66
61

60

64

62
58

72

68 66
58

56

50
Levels %4

61

The lowest scores for these indicators werein the WHO African, South-East Asia andWestern Pacific regions (Figure 1). The highest
average score, at 66%, was achieved forindicator C2.1, related to national focal point
functions under IHR. Lowest average scores
were achieved for indicators C3.1 and C4.1
(58% and 56%, respectively), while 49 of the
183 reporting States Parties scored 60% orless for indicator C2.2 on multisectoral IHR
coordination and mechanisms. Furthermore, thejoint external evaluation (JEE) indicator “IHR
coordination, communication and advocacy”
scored an average of only 55% across all six
WHO regions (regional variation 39% to 86%)
based on 106 JEE reports reviewed in January
2020. This indicator emphasizes the needfor a national “mechanism for multisectoral/
multidisciplinary coordination, communicationand partnerships to detect, assess and respondto any public health event or risk” (27). Among
the recommended priority actions based on the
results of the JEE in the countries with gaps
in coordination, over 50% recommended thedevelopment and dissemination of standard
operating procedures for the coordination of all
sectors (70%) and establishment of a structured
and formalized framework for such coordination(60%). Other suggested key activities include
the development of a plan for multisectoral
coordination, simulation exercises to testlevels of coordination, training, and sustainablefinancing for coordination efforts.

75

73 73 74

71
64

70
69

61

63
58
55

55

55

56

55

52
47

47
41

40

69

68

40

40

30
20
10
0

••
•

AVG. Global
Capacity

AVG. AFRO
Capacity

AVG. AMRO
Capacity

AVG. EMRO
Capacity

AVG. EUROCapacity

AVG. SEARO
Capacity

AVG. WHO
Capacity

Avrg Coord
C2.1 National IHR Focal Point functions under IHR
C2.2 Multisectoral IHR coordination mechanisms
C3.1 Collaborative effort on activities to address zoo noses
C4.1 Multisector ai collaboration mechanism for food safety events

Figure 1. SPAR average scores for selected indicators related to coordination, by WHO region (%)

Key elements of multisectoral preparedness coordination

Multisectoral coordination can strengthencountry ownership, accountability, stewardshipof resources, and organizational effectivenessaround health emergency preparedness, readinessand response. It is important to recognize thatthe capacity to assist in preventing, detecting
and responding to public health risks and healthemergencies exists within a wide variety of
relevant sectors beyond the human health sector.
The consideration of context-specific priorities
and leveraged mechanisms that reflect thedifferent needs and contributions of the relevant
stakeholders are the pillars of effective andsynergetic multisectoral coordination for healthemergency preparedness and health security.

2.4	Stakeholders relevant for healthemergency preparedness andhealth security
Human health, animal health and environmental
sectors. These sectors – considered together
within a “One Health” approach – are identified
as key sectors for multisectoral coordinationof health emergency preparedness and healthsecurity due to the widespread recognition of the
impact on human health of zoonotic spillovers
and zoonotic diseases (18). Disease outbreaks
such as SARS, pandemic influenza A (H1N1),
avian influenza (H5N1), Middle East respiratory
syndrome, Ebola virus disease and Zika virus
disease have been catalysts for the human andanimal health sectors to collaborate closely. The
animal health and environmental sectors add
valuable expertise in the prevention of, detectionof, and response to disease outbreaks transmitted
from sick animals or contaminated environments(21). Health security in this context is alsointerlinked with food security, access to safe waterand sanitation, and the building and safeguardingof resilient communities and livelihoods. While thiscross-sectoral collaboration for health emergency
preparedness is already to some extent continuing
in many countries, engaging the perspective andfunctions of One Health stakeholders is essential
and needs to be advanced.
Finance sector. Engagement of the financesector is also crucial, though too often the sector
is overlooked as a main stakeholder for successful
health emergency preparedness and healthsecurity. The ministry of finance plays a central
role in planning at all levels and ensuring robust
financing of health emergency preparedness andhealth security as part of wider health systemstrengthening. The involvement of ministries
of finance in preparing for – rather than only
responding to – health emergencies is not only
essential but financially sound. The integrationof health emergency preparedness priorities into
national expenditure frameworks, budgets andsectoral plans, and financing these from domestic
rather than international funding sources, are
key components of the discussion. The economic
impact of health emergencies is devastating.
Average annual economic losses of 0.7% of global
gross domestic product due to pandemics areprojected over the coming decades (28). This
is in contrast with the comparatively modest
investment required for health emergency
preparedness that could yield significant returns.
Foreign policy and international relations.
These have a direct influence on how countries
can work together for health emergency
preparedness in today’s interconnected world.
Epidemics can lead to economic decline, social
destabilization and unrest, with implications
for national and international security. Travel
and trade sanctions imposed by governmentson countries affected by outbreaks can harm
economies and relations. As viruses and diseases
do not respect borders, public health needs to beunderstood as a decisive factor in international
diplomacy, with foreign policy bearing a
responsibility for strengthening global healthsecurity (29). Health emergency preparedness
is a matter of national and global security and iscritical in enhancing collaboration on cross-borderhealth security threats. Collaborative foreign
policy on global health allows for better access to
information, technologies, medicines and vaccines,
and improves accessibility to these resources byvulnerable populations. This includes both building
up preparedness capacities within countries andenabling access to capacities in other countries
when health emergencies occur (for example,
access to advanced laboratory testing capabilities).
Foreign policy can also serve to mitigate thepotential threat to national and global healthsecurity of deliberate actions, such as intentional
release of biological agents, and can act as abridge for peace (30). Foreign policy stakeholders
have a clear place at the table in discussions on
multisectoral coordination for health emergency
preparedness and health security.
Ministries of interior and defence. Engagementwith ministries of interior and ministries

56

Multisectoral preparedness coordination frameworkof defence can contribute significantly tostrengthening health emergency preparedness
and health security, particularly relating to
specific efforts for preparedness of cities
and urban settings. Coordination with thesestakeholders can provide intelligence, expertiseand resources for engaging local infrastructure
and authorities, as well as assistance withlogistical requirements for responding tocomplex public health emergencies. In addition,these ministries are crucial for the mitigation ofsuch public health threats as chemical, biological,
radiological and nuclear incidents, whether
intentional or otherwise. While the mandate of
the national military and medical armed forces
in many countries is to provide assistance incase of emergency, their expertise can also be
systematically leveraged for national healthemergency preparedness (31, 32).
National parliaments. While the sectors of
the public administration are vital actors instrengthening health emergency preparedness
and health security, all other public sectors may
also contribute as part of a Health in All Policies
approach. In this vein, national parliaments
provide a multisectoral platform that can supportand sustain political will, representing an additional
layer of support in advancing multisectoral
preparedness coordination. Parliaments are
responsible for adopting and monitoring laws,
policies and strategies, and hold governments
accountable for their effective, efficient andtransparent implementation. Through theiroversight powers, they can ensure that IHR
commitments are translated into action and canapprove budgets and allocations that allow corepublic health security capacities to be sufficiently
funded. Parliaments can advocate, facilitate andformalize multisectoral engagement with othersectors to realize productive alliances for healthemergency preparedness. Meaningful partnership
between the health sector and parliaments isbeing advanced through the 2018 Memorandumof Understanding between WHO and the InterParliamentary Union (33), and adoption by theInter-Parliamentary Union in 2019 of a resolution
to achieve universal health coverage by 2030 (34).
Private sector. The private sector – particularly
with regard to trade, transport and tourism– is heavily impacted by health emergencies.
Major financial losses pose a threat to individual
corporations, while restricted travel and tradedecreases mobility and can disrupt a country’s

infrastructure and cause economic instability.
Private sector engagement can add value
both in health emergency preparedness andduring emergencies, when the private sector
frequently provides large and rapid mobilization
for local response efforts, though collaboration
often ceases soon after the end of the crisis.
Continuous engagement with corporate
stakeholders provides a better understandingof the private sector’s experiences and needs
during public health emergencies. This canhelp identify incentives for the private sector
to collectively engage in strengthening healthemergency preparedness. Recent evidence(28) illustrates the benefits for businesses inincluding risk assessments for disease threats
into their planning processes. The private
sector can invest in multisectoral preparedness
coordination alongside efforts to ensure business
continuation (35). In practice, businesses
could decide to include health among the bestpractices in the industry impact assessment
tools, continuity plans, and safeguarding
mechanisms, or they may add emergency
preparedness to the occupational health andsentinel surveillance systems of company healthclinics. Intensive engagement of the private
sector in health emergency preparedness will
be required in countries that are heavily reliant
on complex networks of private health careproviders (for example, ambulance systems andhospitals) in order to ensure adequate support
and capacity. The private sector’s challenges inand (often innovative) contributions to publichealth emergencies can only be addressed byincluding the private sector as an integral part ofmultisectoral preparedness coordination.
Non-State actors. These play an important rolein community engagement for health emergency
preparedness and response, mainly due to theirexperience with and access to local, religious,
vulnerable or marginalized communities.
Countries need to assess the most effective
ways to engage non-State actors based on
country priorities and the technical and logisticalcapabilities of those actors. Non-State actors
can often make a significant contribution to themultisectoral preparedness coordination in theareas of outreach, specialized technical expertise,
local human resources, and communal data,services and technologies. Examples include
academic research or collaboration between
civil society stakeholders and public healthinstitutions providing epidemiological data on

Key elements of multisectoral preparedness coordinationdisease threats (36), mobile technologies toassist disease surveillance, civil society support
for community engagement, and advocacy
and risk communication across large areas andsubpopulations. This relevant information, all ofwhich can complement governmental resources,
can be integrated to enrich health emergency
preparedness and advance health security.

Box 2 gives an example from the United States of America of multisectoral preparedness coordination.

United States Global Health Security Strategy: a national and global
approach to prevent, detect and respond to infectious disease threats
Together with the National Security Strategy, the National Biodefense Strategy, and the United States executive
order on the Global Health Security Agenda, the United States Global Health Security Strategy is designed to guidethe United States Government in protecting the United States of America and its partners abroad from infectious
disease threats. The strategy pursues three interrelated goals:• strengthen partner country global health security capacities• increase international support for global health security• establish a homeland prepared for and resilient against global health security threats.
Strengthening partner country global health security capacities involves collaboration with partners, including
countries, multilateral organizations, and nongovernmental stakeholders, through the Global Health Security Agenda
to strengthen and sustain capacity to prevent, detect and respond to infectious disease threats. This includes
working with partners to make progress towards achieving IHR core public health capacities while supporting
implementation and compliance with other international frameworks. Activities will be multisectoral, leveraging thestrengths of numerous United States departments and agencies. Support for capacity-building in selected countries
is intended to be temporary, followed by a transparent and systematic transition to sustainable health security
capacities in the partner country. The United States Government’s support is targeted based on global health security
risks, policy priorities, and national security, and activities will be milestone driven and time limited.
Increasing international support for global health security involves coordinating with partner governments,
multilateral organizations and the nongovernmental sector to promote sustainable donor and domestic financing
to build health security capacity beyond the lifespan of the United States Government’s investments. The UnitedStates will use bilateral, regional and multilateral engagements to encourage countries to make health security anational priority, and to invest in their own domestic capacities. The United States will support the inclusion of all
relevant sectors to strengthen health security, including human, animal, and environmental health sectors, as well as
diplomatic, defence, security, finance and research disciplines.
Establishing a homeland prepared for and resilient against global health security threats includes accelerated
research on medical countermeasures, planning for clinical trials during emergency response, and communicating
better with affected populations on public health measures, including vector control and research goals. This
also includes enhancing and sustaining critical health security capacities for epidemiology, surveillance, medical
entomology and laboratory diagnostics, among other technical areas.
The Global Health Security Strategy emphasizes the value of taking a multisectoral approach to drive health security
outcomes, and defines areas of coordination, roles and responsibilities. It outlines opportunities for interagency
coordination, including domestically, through a GHSA Interagency Review Council, and overseas, utilizing multisectoral
embassy teams for partner country capacity-building. Key roles for departments and agencies are defined in thestrategy, with an overall emphasis on multisectoral coordination to achieve the three interrelated goals.

78Multisectoral preparedness coordination framework3	Key elementsof multisectoral
preparedness
coordination
In each of the following subsections, key elementsof multisectoral preparedness coordination are
described, which countries may consider when
taking action within the context of the multisectoral
preparedness coordination framework.

3.1

High level political commitment

3.1.1. Country ownership
Seeking high-level political commitment andsupport. This is necessary to provide the mandate
for the multisectoral preparedness coordination of
stakeholders beyond the traditional health sector.
Political assertion is crucial, as it enables the required
whole-of-government and whole-of-society
approach to coordination. This includes seeking theengagement of the prime minister’s offices, highgovernmental and ministerial councils, and offices
in charge of overarching planning or policy related
to matters of national concern in order to bring
together public, private and non-State stakeholders.
Embedding health emergency preparedness into
overarching frameworks. Regional and global
initiatives and frameworks (such as the Asia PacificStrategy for Emerging Diseases and Public Health
Emergencies (APSED III), the African Public Health
Emergency Fund, and the Europe 2020 Strategy)
may help to strengthen national health security
objectives by working towards a common goalat the political level. This alignment incentivizes
multisectoral participation and coordination at thestrategic and operational levels.
Engaging the national parliament. This isnecessary to ensure the endorsement of relevant
legislation and other measures (laws, regulations,directives, acts and decrees, policies andstrategies) that support multisectoral coordinationfor emergency preparedness and health security.
Parliaments can support enactment of healthsecurity measures and hold governments
accountable for health emergency preparedness
and IHR implementation. They are effective andinfluential multisectoral platforms for promoting
country ownership for enhanced country healthemergency preparedness (see also section 2.4).

3.1.2 Champions and leadership
Identifying champions in relevant sectors.
High-level political commitment is reinforced bychampions promoting multisectoral preparedness
coordination with conviction and personal
engagement within their own sector, but alsowith the ability to reach stakeholders beyond.
Champions are crucial to initiate multisectoralcollaboration and advocate coordination acrossmultiple sectors based on both evidence-based
information and qualitative data. Champions
may be identified in the sectors already involved(particularly the health sector), as well as in sectorsthat have a good track record of cross-sectoral andmultisectoral coordination or have good relations
and networks with other relevant stakeholders.
Selecting leaders for the coordination process.
This requires clarity on the purpose and scope ofthe task, and identification of the stakeholders
involved in the multisectoral preparedness
coordination. Leadership may be placed in asingle ministry or institution, may be shared, or
can rotate among stakeholders on an agreed
schedule. Delegating leadership to an overarching
governmental body (for example, prime minister’s
office, ministerial council, high-level planning body)rather than a line ministry (such as the Ministryof Health) may result in broader acceptance,
wider outreach and a more cooperative approach.
Effective leadership requires political supportand selection of a lead with appropriate status,
management skills and ability to bring various
public and private sectors and stakeholders to thetable. The lead is tasked with institutionalizing
the multisectoral preparedness coordination
by involving all relevant public and private
stakeholders from the start of the process,setting targets for coordination and chairing thesteering committee. Leading the multisectoral
preparedness coordination requires the adoptionof a comprehensive understanding and vision ofhealth emergency preparedness and health security
within a whole-of-government approach.
Both champions for and leadership ofmultisectoral coordination are key for the successof the coordination. They will enhance mutual
trust, a sense of ownership, stakeholder buy
in and accountability during the process (seesubsection 3.3.1).

Key elements of multisectoral preparedness coordination

3.2	Formalizing multisectoral
preparedness coordination
3.2.1	Developing multisectoral
coordination structures
Assessing existing multisectoral coordination
structures. Countries tend to consider
multisectoral coordination when responding
to a public health event, for example as part ofdisaster risk management, which often subsides
when the emergency has ceased. Multisectoral
preparedness coordination needs to aim at
ensuring functional and sustainable mechanisms.
Any pertinent and existing coordination structure
should be assessed for suitability as a potential
mechanism for multisectoral coordination for
health emergency preparedness and healthsecurity. This initial assessment will help toavoid unnecessary duplication of coordination
mechanisms, to identify valuable lessons learnedin the specific country context, and to determine
the best fit for the integration of relevant sectors
and stakeholders.
Constituting a steering committee. High-level
coordination can be exerted through a steeringcommittee combining political representationand technical expertise to address strategic,
technical and managerial aspects of thecoordination. The committee facilitates thebuilding of a collaborative, cooperative andsupportive environment for sharing knowledge,
information and experience among participating
sectors and stakeholders, between the nationaland subnational levels, and with regional andglobal actors and networks. Its tasks include
assessing and providing relevant informationand data, and commissioning research toprovide strategic guidance on multisectoral
preparedness coordination. The committee has
the authority to take strategic decisions, develop
terms of reference for roles and responsibilities,
and set targets and indicators in relation to
the multisectoral preparedness coordination.
The committee can mandate advisory groups,
technical working groups, and task forces
to provide guidance, conduct research andimplement activities on specific strategic ortechnical areas. The steering committee shouldmeet regularly and will be accountable tothe lead overarching governmental body (seesubsection 3.1.2), supported by a secretariat.
Availability of committed and dedicated funds
will increase the operational effectiveness of thecommittee (see subsection 3.3.3).
Initiating technical working groups. The
multisectoral technical working groups are theplatforms for a range of technical activities andoutputs conceptualized and mandated by thesteering committee, including conducting research,developing action plans and standard operatingprocedures, and organizing and implementing
such activities as simulation exercises and after
action reviews. The working group is convened
on a regular basis for systematic exchange of
information related to public health risks andthreats in the country. The focus of technicalworking groups can include strengthening IHR corecapacities and related technical areas, addressing
stakeholder-specific needs and contributions
to emergency preparedness, and linking andintegrating the subnational, regional and global
levels in country activities for health security, as
advised by the steering committee.

Box 3 presents an example from Indonesia of multisectoral preparedness coordination.

Indonesia: high-level commitment to multisectoral
preparedness coordination
In June 2019, the President of the Republic of Indonesia signed a presidential instruction
aimed at increasing the country’s capacities to prevent, detect and respond to infectious
diseases, pandemics, bioterrorism and other chemical, biological, radiological or nuclear risks
and threats. The measure aimed to improve national resilience and provide a frameworkfor how institutions and ministries should collaborate and coordinate across sectoral lines,
including at the subnational level, to counteract those risks and threats.

910 Multisectoral preparedness coordination framework

The presidential instruction provides specific instructions to 24 ministers, agency heads, mayors andthe leaders of the armed forces and national police. All are directed to undertake an evaluation andreview of the current health security situation and establish relevant policies, laws and regulations,while acting in a coordinated and integrated manner.
The presidential instruction decrees that coordination for outbreaks, epidemics, pandemics andother public health emergencies related to security falls under the Coordinating Minister for
Politics, Law and Security. The Coordinating Minister for Human Development and Culture is
responsible for the preparedness and response coordination that does not have a security element.
Both ministers are tasked with:•	increasing the capacity of ministries and institutions under their coordination to prevent, detect
and respond to threats;•	establishing guidelines for increasing synergy, cooperation and collaboration in planning,drafting, implementing and evaluating relevant policies;•	developing an international cooperation framework in coordination with the Ministry of Foreign
Affairs to improve the capability to prevent, detect and respond to the threat of global publichealth emergencies.
Both the Coordinating Minister for Politics, Law and Security and the Coordinating Minister for
Human Development and Culture report to the Cabinet Secretary, who monitors and evaluates theimplementation of the presidential instruction and reports the results to the President.
The presidential instruction provides directions carefully tailored to each of the 24 relevant
ministries and agencies. For example, the Minister of Foreign Affairs is tasked to improvecoordination of cross-border cooperation, while the Minister of Finance is instructed to provide
support for health security budget allocations, strengthen supervision of the traffic of goods
through Indonesian customs, and review and improve legislation related to the traffic of goods.
The presidential instruction offers an example of high-level commitment to multisectoral preparedness
coordination that can serve as a model for other countries in the South-East Asia Region and globally toadapt to their own specific contexts and needs in strengthening health security.

3.2.2	Stakeholder mapping and analysis
Mapping stakeholders. This task, which canbe undertaken using a transparent, methodical
process based on defined criteria, is the basis forselection of relevant public and private sector
entities and stakeholders for multisectoral
preparedness coordination. Inquiries might besent through government channels to identify
stakeholders involved in specific technical areas or
topics related to health emergency preparedness
and health security (20). The complexity of theprocess depends on the scope, objectives, priorities
and tasks to be addressed by the multisectoral
preparedness coordination. The process can be
iterative or continuous, in which case stakeholders
can be added or excluded at a later stage, as
deemed necessary. This helps to keep themechanism as inclusive but at the same time aslean as possible. Limiting participation according
to the most relevant sectors and stakeholders will
enhance coordination functionality (see section2.4); if necessary, subgroups relating to specificsectors or topics can be created (see subsection
3.2.1). It is advisable to include sectors andstakeholders that have experience in collaboration
across different sectors and can demonstrate anability to coordinate others and act as subgroup
coordination leads.
Analysing the needs and contributions ofmultisectoral stakeholders. For some targeted
sectors and stakeholders, their roles in contributing
to health emergency preparedness and healthsecurity may not be obvious at the beginning.
Stakeholder mapping and analysis can not only
assist in systematically determining all relevantpublic and private stakeholders and non-State
actors, but it can also identify needs, areas in which
each actor can add the most value, (potential) typesof contributions, and incentives for engagement
across the various sectors and stakeholders for
multisectoral preparedness coordination.

Key elements of multisectoral preparedness coordination

3.2.3 Joint needs assessment
Jointly collecting data on health risks and threats.
Once all relevant stakeholders for the multisectoral
preparedness coordination have been selected, ajoint needs assessment will identify gaps and needsaround emergency preparedness and health security.
Data on health risks and threats and general healthindicators are vital to inform decision-making forthe multisectoral coordination for health emergency
preparedness and health security (37, 38). Healthinformation system routine data, internal or external
assessments (such as joint external evaluation
and after action reviews), and prevalence and risk
mapping are common data sources. Reviewing past
public health events or using simulation exercises
helps to identify additional gaps and potential needfor collective support.
Sharing of multisectoral information. This
allows adequate risk and vulnerability mapping.
Joint assessment across sectors enables exchangeof data and perspectives, including on vulnerable
populations. Sectors and stakeholders engaged
in the multisectoral preparedness coordination
may have conducted or have access to sectorspecific analyses related to health security. In
addition, public health institutes, academia andother non-State actors often collect specialized
data, and might be able to assist in expanding
research on priority areas (see section 2.4). A
lack of data may require funding requests forresearch so that better data can be generated
to improve decision-making (see subsection
3.3.3). Collaborative publication based on thework implemented through the multisectoral
preparedness coordination can sustain
cross-sectoral partnership beyond the actual
coordination process (see subsection 3.3.2).
Verifying parameters through the assessment.
The joint assessment not only indicates gaps
and needs in the country’s health emergency
capacity, it also provides an opportunity to (re)define objectives and expected outcomes inorder to harmonize expectations among all
stakeholders. Keeping track of the engagement
and approaches of the various sectors andstakeholders is vital in organizing concerted
efforts (see subsection 3.3.4). There is a need forsufficient flexibility in multisectoral preparedness
coordination to allow modification of workflow
and measures for enhanced results and progress.

3.2.4	Formalizing the multisectoral
preparedness coordination
Benefits of formalization. Depending on country
context and purpose, different types and levelsof formalization can be considered to support
multisectoral coordination for health emergency
preparedness and health security. The options
include memoranda of understanding or various
legislative measures, such as regulations, directives,
decrees, and acts or laws (depending on country
context). Even though defining a legal status
or formal structure is often time consuming,
formalization unites participation of different
sectors and stakeholders, defines roles andresponsibilities, facilitates coordination needed at
different levels and enhances sustainability.
Formalization at the highest administrative
level possible. High-level political support,
including parliament, provides the leadershipwith a strong official mandate and ensures
acceptance across diverse sectors (seesection 3.1). Formalization needs to address
both strategic and operational issues, and to
consider options at the subnational, regionaland global levels. Legislative changes mightprovide the strongest mandate for multisectoral
preparedness coordination but are likely torequire lengthy processes. The continuous
engagement of national parliament in thisprocess is advisable (see section 2.4). Dependingon the country and legal context, memoranda ofunderstanding can help to define sectoral roles
within the multisectoral coordination for healthemergency preparedness and health security.
These are easier to arrange and more adaptable
than more formal measures, though they provide
less authority outside the organizations involved.
Memoranda of understanding and other formsof organizational commitment can be reinforced
through circulars and other legal documentsthat can support effective implementation at alllevels. In some countries and situations, informalgroups or tasks forces represent the mostfeasible option, though they lack clear reportingand command structures, and their decisions
might not be broadly accepted.
Formalized accountability frameworks for thesteering committee and technical working
groups. Such frameworks can lead to enhanced
quality of the multisectoral preparedness
coordination and to strengthened governancemechanisms (see subsection 3.3.4). Accountability

1112 Multisectoral preparedness coordination framework

frameworks have an impact on the processes
for decision-making and consensus-building,data sharing, documentation and information
management, and agreed approaches for
feedback mechanisms, conflict resolution andmediation (see subsections 3.3.1 and 3.3.2).

3.3	Implementing multisectoral
preparedness coordination
3.3.1	Transparency, trust andaccountability
Building transparency and accountability at
the onset. This contributes to an environment ofmutual trust and respect, which is essential for
effective coordination across multiple sectors.
A formalized coordination process further
enhances transparency and accountability(see subsection 3.2.4). While multisectoral
preparedness coordination is facilitated by aculture of open communication and definedroles and responsibilities for each sector,
clearly designating and communicating shared
responsibilities is equally important. Successfully
establishing trust among the stakeholders ofthe multisectoral preparedness coordination
will result in more effective planning for andresponding to public health emergencies.
Establishing an understanding of the common
goals and expectations. Frequently, challenges
may arise from the reluctance of different
sectors to share data, information and resources
due to concerns about interference or lossof sovereignty. Conflicts of interest need to
be openly discussed at the beginning of themultisectoral preparedness coordination so that
potential misunderstandings can be avoided
and resolved, and the most equitable approach
followed. The involvement of diverse sectors
and stakeholders, including the private sector
and non-State actors, may give rise to concerns
related to conflict of interest. It is important tounderstand that it is both a challenge and an
advantage to engage multisectoral stakeholders.
Diverse perspectives and ways of working canprovide complementary contributions to healthemergency preparedness and health security(see section 2.4). The needs, incentives andcontributions of multisectoral stakeholders arelikely to differ. These can be unified by strong
leadership representing a whole-of-government
approach to the common goal of enhancing
country health emergency preparedness.

3.3.2 Communication
Effective communication. This is a prerequisite
for successful multisectoral coordination for
health emergency preparedness and healthsecurity. Regular reporting to government
offices and parliament enhances trust
and motivates further engagement (39).
Communication needs to emphasize theimportance of multisectoral engagement for
health emergency preparedness to increasebuy-in from all relevant stakeholders, including
the public. Adequate communication involves
establishing regular exchange of information as
well as ad hoc updates regarding the objectives
and activities of the multisectoral preparedness
coordination.
Internal communication. This addresses
communication between members of themultisectoral preparedness coordination,
including the different decision-making or
operational levels that need to be informed.
The frequency of the exchange depends on
the scope of the coordination. Face-to-facemeetings at the beginning of coordination
are crucial to bring together the various
sectors and stakeholders, which might nothave worked together before. Stakeholders
should also monitor the effectiveness of thecoordination mechanism itself, as well as dataprotection and ethical issues that arise (seesection 3.3.4). A cross-sectoral electronic
platform for shared documents allows for easein providing and sharing information, thus
contributing to effective implementation.
External communication. This engages
stakeholders outside the coordination process,for example the media and the public, throughcommunication materials, published reports,press communiqués, conferences, social media
or other means. Technical and communication
experts from the different sectors should
develop a joint communication strategy. Risk
communication and communication materials forcommunity engagement should emphasize themultisectoral stakeholders involved in emergency
preparedness activities. The designation of an
official spokesperson may be useful to ensure
consistent messaging. Collaborative publication
based on the work implemented through themultisectoral preparedness coordination cansustain cross-sectoral partnership beyond theactual coordination process.

Key elements of multisectoral preparedness coordination

Box 4 presents an example of multisectoral preparedness coordination from Finland.

Finland: Security Strategy for Society
The Security Strategy for Society is a government resolution that harmonizes Finnish national
principles regarding preparedness, including emergency preparedness, and guides the actions
taken by the administrative branches.
The cooperation model for comprehensive security provides the basis for preparedness and taking
necessary actions in the event of various disruptions. In the model, all actors share and analyse
security information, prepare joint plans, and train and work together. The cooperation model
covers all relevant actors, from citizens to the authorities, within a whole-of-society approach.
Cooperation is based on statutory tasks, cooperation agreements and the Security Strategy for Society.
The practical implementation of comprehensive security takes place on the basis of both crossadministrative strategies and strategies for individual administrative branches. These include the Internal
Security Strategy and the Finnish Cyber Security Strategy, and their relevant implementation programmes.
The Security Strategy for Society was drawn up through broad-based cooperation involving
government, the private sector, nongovernmental organizations, communities and citizens.
Each administrative branch is responsible for implementing the strategy within its competence.
The Security Committee monitors the strategy’s implementation and coordinates cooperation
measures, together with the ministries’ heads of preparedness.
The heads of preparedness coordinate the measures between the ministries in all security situations. The
meetings of the heads of preparedness are chaired by the Head of Preparedness of the Government. Eachministry has a head of preparedness, a preparedness committee and a preparedness secretary.
The Security Strategy for Society provides the preparedness guidelines for the administrative
branches in vital functions for society: leadership, international and European Union activities,
defence capabilities, internal security, the economy, infrastructure and security of supply,
functional capacity of the population, service provision, and psychological resilience.
For example, the Ministry of Social Affairs and Health has responsibilities that include ensuring
access to social welfare and health care services during incidents and emergencies. The Prime
Minister’s Office, Ministry of Foreign Affairs, Ministry of Finance, Ministry of Defence, Ministryof the Interior, Ministry of Education and Culture, Ministry of Economic Affairs and Employment,
Ministry of Agriculture and Forestry, Ministry of Transport and Communications, and Ministry ofJustice each also have their own roles and responsibilities under the Security Strategy for Society,including areas for coordination with other ministries.

3.3.3	Health security preparedness
funding
Allocating domestic funding for healthsecurity preparedness. This will help ensure
the sustainability of the process. Recent workon national emergency preparedness and healthsecurity financing conducted by the World Bank(40) and collaborating partners showed that only asmall amount of additional (per capita) expenditureis needed every year for countries to maintain or
improve their capacities to detect, prevent andrespond to health security challenges. Multisectoral
preparedness coordination can support increased
efforts to cost, budget and track expenditure
for health security preparedness. This includes
identifying health emergency preparedness gaps
through technical evaluations, development andlinking of costed action plans (including national
action plans for health security), mapping ofresources, for example using the WHO REMAP tool(41), and prioritization exercises to ensure financing
priorities are included in national expenditureframeworks, budgets and sectoral plans.

1314 Multisectoral preparedness coordination framework

Engaging the ministry of finance. The ministryof finance is instrumental in planning for healthemergency preparedness and health security. Its
engagement will allow a common understandingof priorities and associated financial requirements
and needs for appropriate emergency preparedness
in the specific country context. Dedicated funding
for multisectoral coordination is required for aneffective process. The active engagement of theministry of finance in the process will provide
greater leverage and advocacy in the area of
health emergency preparedness specifically, andstrengthen health system-related budgeting in
general. A focal point for budgeting and financing
should be part of the steering committee tofacilitate adequate funding allocation for priority
preparedness items (see section 2.4).
Multisectoral preparedness coordination as aninvestment. Financing the coordination itself does
not necessarily require large amounts of resources
but does demand effective planning. In mostcountries, limited human resources is one of themain challenges. Careful planning and budgetingis important, particularly in heavily centralized
systems. The financial needs assessment conductedwhen deciding on the scope of the multisectoral
preparedness coordination will identify thefunding priorities. The role of public and private
stakeholders as well as non-State actors in funding
and contributing to the multisectoral preparedness
coordination should be to be explored.

3.3.4	Monitoring the multisectoral
preparedness coordination
Good governance through measuring
progress of the multisectoral preparedness
coordination. This not only verifies coordination
processes but can also validate if the alignment
yields positive results for health emergency
preparedness and health security. An effective
monitoring and evaluation process should
be defined at the onset of the task, tailoredto country context and needs. Tracking
implementation and determining the extent
to which agreed objectives and goals havebeen reached ensures the effectiveness ofthe coordination mechanism. Assessing themultisectoral implementation is only beneficial
when reviewed routinely by the steeringcommittee. This enables identification of
any necessary amendments to strategic andoperational procedures, and related changes in
specific capacities or resources. Progress updates
as part of regular briefings (see subsection 3.3.2)
are key to keeping the involved sectors andstakeholders informed, engaged and accountable.
Role of the IHR Monitoring and Evaluation
Framework. The IHR Monitoring and Evaluation
Framework can support multisectoral
preparedness coordination by providing tools
to assess country emergency preparedness
capacity. These tools include State Party selfassessment annual reporting, joint external
evaluation, after action review (42) andsimulation exercises (43). The tools of the IHRMonitoring and Evaluation Framework offer
a variety of established methodologies toassess and enhance emergency preparedness
capacities. Additional monitoring tools,
including indicators, may be developed toreflect stakeholders’ roles, responsibilities,
needs and contributions to emergency
preparedness and health security in the
country. Successful outputs and outcomes are
related to strengthened coordination between
public and private stakeholders and non-State
actors for building and maintaining IHR corecapacities. Effective multisectoral preparedness
coordination will not only improve countries’
capacities to prevent, detect and respond to
public health risks and threats, but will alsoenhance collaboration and coordination before,
during and after public health emergencies,
building upon a tried and tested operational
multisectoral preparedness coordination.

Key elements of multisectoral preparedness coordination

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Key elements of multisectoral preparedness coordination

Annex 1: Literature review
Results of the literature review
An analysis was done based on the 24 peerreviewed articles fitting the inclusion criteria. The
review found relevant examples of multisectoralcollaboration and coordination from 12 different
countries (Australia, Cameroon, Canada,
Denmark, India, Italy, the Philippines, theRussian Federation, Sweden, Thailand, Uganda
and the United Republic of Tanzania) addressinga variety of topics, for example diseases suchas brucellosis and rabies, but also areas such as
agriculture, education, disaster risk management,
financing and legal preparedness.
The majority of articles called for stronger andenhanced multisectoral coordination, but there
were also studies concluding that intersectoral
action for health could not be achieved bystructural fixes, which often reproduced theorganizational issues they were intended toovercome, and created activities that wereparallel to and decoupled from daily operations.
To avoid these problems, the following factors
for successful multisectoral coordination werementioned by several authors:•	strong leadership, possibly at a high political level• mapping of stakeholders• inclusion of key players and issues•	early joint assessment and definition of themission and strategy• formalization of coordination• use of a coordination committee• definition of measurable outcomes•	monitoring of the success of the coordination
mechanism• creation of trust and respect• generation of evidence for decision-making• establishment of communication channels• allocation of funding.
Following the literature review, these aspects
were discussed with Member States, and thosepoints that were considered as important wereaddressed in preparing this framework.
The database used was PubMed. This is afree search engine accessing primarily the
MEDLINE database of references and abstracts.
MEDLINE (Medical Literature Analysis andRetrieval System Online, or MEDLARS Online)
is a bibliographic database of life sciences andbiomedical information. It includes bibliographic
information for articles from academic journals
covering medicine, nursing, pharmacy, dentistry,veterinary medicine and health care.
The review focused on examples or plans ofcollaboration and coordination and lessons
learned. For the first search level, all articles withany version of the words cross-sectoral, intersectoral or multi-sectoral and health in the title
were included (n = 189). To address the interestin examples from national level, articles where
the titles were quoting community, city or local
were excluded from the further analysis (n =23). As the interest lay in health security andthe IHR (2005), other specific topics (health care,
depression, mental, equity, social determinants,
health promotion) that were frequently the focus of
the articles were systematically excluded (n = 59).
The titles of all remaining articles were scanned by
the reviewer for relevance, which led to exclusionof another 51 articles. By scanning the abstract of
the remaining 56 articles, 32 not relevant articles
could be excluded, leading to 24 peer-reviewed
published articles, which are included in thefollowing literature review (Figure A1.1).
The database used was Pubmed. This is afree search engine accessing primarily the
MEDLINE database of references and abstracts.
MEDLINE (Medical Literature Analysis andRetrieval System Online, or MEDLARS Online)
is a bibliographic database of life sciences andbiomedical information. It includes bibliographic
information for articles from academic journals
covering medicine, nursing, pharmacy, dentistry,veterinary medicine, and health care.
The review focussed on examples or plans ofcollaboration and coordination and lessons
learned. For the first search level all articles withany version of the words cross-sectoral, intersectoral or multi-sectoral and health in the title
were included (n=189). To address the interest in
examples from national level articles where thetitles were quoting community, city or local were
excluded from the further analysis (n=23). As theinterest lies in health security and IHR (2005)
other specific topics (health care, depression,
mental, equity, social determinants, healthpromotion) that were frequently the focus of
the articles were systematically excluded (n=59).
The titles of all remaining articles were scannedby the reviewer for relevance which lead to an
exclusion of another 51 articles. By scanning

1920 Multisectoral preparedness coordination framework

the abstract of the remaining 56 articles, 32 not
relevant articles could be excluded leading to24 peer reviewed published articles, which areincluded in the following literature review.
(see graph 1)

Graph 1. Literature inclusion flowchart

Database: Pubmed; search with the following words in the title• c ross-sectoral OR cross-sector OR crosssectoral OR crosssector OR• inter-sectoral OR inter-sector OR intersectoral OR intersector OR•m ultisector OR multisectoral OR multi-sector OR multi-sectoralAND•h ealthn=189

In title

YES (n=23)• c ommunity OR• c ity OR• localNO (n=166)

YES (n=24)

In title•h ealth care
NO (n=142)
In title

YES (n=8)•d epression OR•m ental

Excluded
NO (n=134)

In title• e quity OR• s ocial determinants OR•h ealth promotion

YES (n=27)

NO (n=107)
Relevance by scanning title

NO (n=51)

YES (n=56)
Relevance by scanning abstract
YES
Included in the review(n=24)NO (n=32)

Key elements of multisectoral preparedness coordination

Results
Axelsson and Bihari-Axelsson describe thecoordination problem as follows: it is alreadydifficult to coordinate different actors within
the health sector, but it is even more difficult tocoordinate actors from different sectors of society(1). This requires voluntary collaboration between
different organizations. According to organization
theory, such inter-organizational relations are
more loosely coupled than intra-organizational
relations, since the different organizations may
not be part of a common hierarchy (2).
Magee writes that the social, economic andpolitical challenges that have accompanied therapidly changing and fundamentally transforming
global environment have created unique social
challenges that demand cross-sectoral solutions(3). In pursuit of these new partnerships in thehealth sector, there should be a bias towards
action, early organization and prevention.
Successful cross-sectoral partnerships in healthare fundamentally inclusive and actively involvedin bridging government, business, academia andcivil society. They favour joint value creation.
Careful early assessment for mission andstrategy, inclusion of key players and issues,
clear measurable goals, and political readinessare critical elements for future success. Use of
an independent expert advisory committee indesign and monitoring of comprehensive publichealth strategies is valuable. Magee describes
possible obstacles to success as absence of
top-level leadership, basic disagreements on thefundamental scientific underpinnings, absence ofstrong prevention programming, hidden political
agendas, exclusion of key sectors, and failure to
identify a key issue and address it proactively (3).
A scoping review by Shankardass et al. identified
and described scholarly and grey literaturereferring to global cases of intersectoral action
for health equity featuring a central role forgovernments (4). The review found 128 uniquearticles describing intersectoral action across 43

countries. A variety of approaches were used
to carry out intersectoral action, but articles
varied in the richness of information included todescribe different aspects of these initiatives. The
authors concluded that the description of thesecomplex, multi-actor processes in the publisheddocuments was generally superficial andsometimes entirely absent, and improvements
in such documentation in future publications
was warranted. They suggested that interviews
be used to facilitate a more comprehensive
understanding from the perspective of themultiple sectors involved (4).
Rasanathan et al. focused in their article on lowand middle-income countries (5). Their results
showed that the focus of the health sector inmost countries was almost exclusively on healthcare services, and the potential of multisectoralcollaboration remained untapped in many lowand middle-income countries. Different sectors
have different contributions to make towards
solving specific health problems. In each case,the profile, interests, incentives, and relationshipsof key individuals and sectors must be mapped
and analysed to inform the design of approaches
and systems to tackle a shared problem.
Collaborative and distributed leadership is key
for effective governance of multisectoral action,with a need to build leadership capacity acrosssectors and levels of government and cultivate
champions in different sectors who can agree
on common objectives. Important ways forward
to support countries to take a multisectoral
approach for health include ensuring that theuniversal health coverage agenda addresses
the capacity of the health sector to work withother sectors, learning from multisectoral efforts
that do not involve the health sector, improving
the capacity of global institutions to support
countries in undertaking multisectoral action,and developing a clear implementation research
agenda for multisectoral action for health (5).

21

22 Multisectoral preparedness coordination framework

Countries

CanadaAustralia

The Public Health Agency of Canada’s Multisectoral Partnerships Initiative, administered by
the Centre for Chronic Disease Prevention, brings
together diverse partners to design, implement
and advance innovative approaches for improving
population health. The article of Willis et al.
describes the development and initial priorities ofan action research project that aims to facilitatecontinuous improvement of the Centre for Chronic
Disease Prevention’s partnerships initiative andcontribute to the evidence on multisectoral
partnerships (8). The initiative, which involves many
traditional and non-traditional partners, is trying toachieve social and economic gains by harnessing
the expertise, resources and reach of diverse
partners. Consultations and the review highlighted
the importance of understanding partnership
impacts, developing a shared vision, implementing
a shared measurement system and creating
opportunities for knowledge exchange. The authors
conclude that the initiative may prove useful for arange of audiences, including other government
departments and external organizations interested
in capturing and sharing new knowledge generated
from multisectoral partnerships (8).

Health in All Policies has been promoted as ameans of embedding concern for health impacts
in the policy-making process. Lawless et al.
report from South Australia, where specificstructures and processes to achieve this havebeen developed and tested among policy officers
and managers in all sectors of government (6).
The primary mechanism of the South Australian
Health in All Policies approach is the health lensanalysis – an intersectoral, partnership process
drawing on public health research methods.
Evaluation findings suggest that the health lensanalyses have resulted in the following: increased
understanding by policy-makers of the impact of
their work on health outcomes; changes in policy
direction; development and dissemination ofpolicy-relevant research; greater understanding
and stronger partnerships between health andother government departments; and a positive
disposition towards employing health lensanalyses in future work. There have long been calls
for intersectoral action in order to achieve public
policy supportive of positive health outcomes.
Evaluation to date suggests that the health lensanalysis is a promising means of moving theagenda from policy rhetoric to policy action (6).
Cameroon
Cameroon had a shortage of human resources
for health, and lacked the economic resources
to support the mass recruitment of new healthworkers. Kingue et al. describe the efforts madeto overcome this situation (7). Since 2006, strong
leadership has facilitated the process of moving
to an evidence-based approach for developmentof human resources for health in Cameroon.
It has encouraged collaboration between theministries involved in the Cameroonian healthsector, fostered relevant discussion and dialogue,
increased trust between the various stakeholders,and promoted a consensus view and approach.
The nongovernmental organizations and nationalsocieties involved in health care in Cameroon
have been able to expand their role, increase theirvisibility and improve their credibility with thenational government and other stakeholders. Even
health workers in remote areas have been able
to contribute to the planning process of humanresources for health. The authors conclude thatstrong leadership is needed to ensure effective
coordination and communication and that together
the main challenges need to be identified (7).

Denmark
Holt, Carey and Rod analysed the decentralized
political system in Denmark, where the 98
municipalities are responsible for welfare services
such as primary education, culture and leisure,social services, elder care, employment services
and local planning (9). Placing these tasks within
the municipal jurisdiction was partly based on
ideas about intersectoral action. To comply withthese expectations, many Danish municipalities
established intersectoral governance structuresand ensured a general mandate for health inmunicipal strategies and policies. Continuous
and frequent processes of reorganization werewidespread in the municipalities. However, they
appeared to have little effect on policy change.
The two most common governance structures
established to transcend organizational boundaries
were the central unit and the intersectoralcommittee. Both these organizational solutions
tend to reproduce the organizational problems
they are intended to overcome. Even if structural
reorganization may succeed in dissolving some
sectoral boundaries, it will inevitably create
new ones. Therefore Holt, Carey and Rod
concluded that it was time to dismiss the ideathat intersectoral action for health could beKey elements of multisectoral preparedness coordinationachieved by means of a structural fix. Rather thanrearranging organizational boundaries, it may be
more useful to seek to manage the silos that exist
in any organization, for example by promoting
awareness of their implications for public healthaction and by enhancing the boundary-spanningskills of public health officers (9).
In another publication, Holt et al. reported on
the intersectoral process of implementing amunicipality-wide health policy in one Danish
municipality (10). They found that the myth ofintersectoralism posed a barrier to the ambitionof moving from overall statements of intent
to more specific plans for action. The process
produced activity, but activity that seemedsomewhat parallel to and decoupled fromdaily operations. Despite elaborate governancemechanisms – which are often recommended as
the means to foster intersectoral collaboration– the process did not entail the expected movefrom rhetoric to action. Particularly, threeelements functioned to avoid the necessary
specification that would direct action: (a)idealization of universal intersectoralism; (b)doubts about economic outcomes; and (c)tensions between inconsistent demands (10).
Larsen et al. also looked into the implementationof intersectoral action for health in one Danish
municipality (11). The results of this case study
indicate that several factors may influence theimplementation and success of intersectoral healthpolicies. Important elements are the compatibility ofinterests among relevant sectors, the identificationof a common framework and actions basedon sound baseline data, political will, citizen
participation, media attention, the commitment of
all stakeholders, the allocation of sufficient (joint)resources, and the policy’s ability to produce benefits.
The fact that benefits are often more difficult to
calculate than immediate costs can hinder project
development; clear common objectives based on
baseline information can help overcome this obstacle
to some degree. It is seen as very important thatthe collaboration itself should be addressed in anintersectoral manner – starting from the initial stagesof policy development and continuing through thestages of implementation and evaluation – insteadof the health sector dominating with its own
perspective on health issues (11).
India
Salunke and Lal describe in their article themultisectoral approach in India, which entails

collaboration among various stakeholder groups(for example, government, civil society and theprivate sector) and sectors (for example, health,environment and the economy) to jointly achievea policy outcome (12). By engaging multiple
sectors, partners can leverage knowledge,
expertise, reach and resources, benefiting fromtheir combined and varied strengths as they work
towards the shared goal of producing better
health outcomes. One of the major advantages
is optimization of usage of resources by avoiding
duplication of inputs and activities, thus improving
programme effectiveness and efficiency. Political
will and mandate at the policy level are necessary
to plan and execute successful multisectoral
coordination. All the major stakeholders needto share a common vision and perspective.
Developing institutional mechanisms helps
to standardize the processes of intersectoral
coordination. Opportunities and mechanisms
for routine multisectoral collaboration include
sufficient allocation of resources and time; open,
inclusive and informed discussion among key
stakeholders; a policy process and policies shaped
and influenced by multisectoral inputs; monitoring
and assessment of collaborative partnerships
for learning and improvement; and evidence
generated and shared on the cross-sectoral
benefits of achieving the stated health goal
through a multisectoral response (12).
Italy
Italy has established health teams to control
brucellosis, a zoonosis affecting livestock andhumans (13). The collaboration of veterinarians,
physicians and other health care workers has
contributed to a decrease in incidence of thedisease in Italy. In the initial phase of the control
programme, an interdisciplinary team was formed
to discuss the general aims and objectives of the
project, jointly training human and animal healthpersonnel on disease surveillance and control.
This course became the key point for healthworkers’ involvement and for the establishment ofintersectoral collaboration (13).
Philippines
Rabies is an endemic disease in the Philippines(14). To address the disease at source,
coordinated efforts are needed involving humanhealth, animal health and local government
units. To address the existing gaps andguide intersectoral collaboration, a practicalintersectoral linking tool has been developed andimplemented. The tool is an operational protocol

23

24 Multisectoral preparedness coordination frameworklinking a network of local key actors involved inrabies detection, reporting and implementationof appropriate interventions. The first results
indicate earlier detection and better preventionof further cases (14).
Russian Federation
Axelsson and Bihari-Axelsson analysed the
public health system of the Russian Federationand suggested clarifying the differentiationof roles and tasks between the different
actors in order to improve their integration.
Organization of public health could be improvedby establishing a national authority to initiate
and support intersectoral collaboration, andestablishing special liaison committees involving
a range of actors – including nongovernmentalorganizations – that could contribute tointersectoral decision-making (1).
SwedenThe main ﬁndings of a study by Mannheimer,
Lehto and Ostlin showed that the Swedish
development correlated with the international
progress and promotion of intersectoral healthpolicy and health impact assessment; that theprocess of policy change was more expert basedat the national level and politician based at the
local level; and that the interest in health impact
assessment was more prevalent from the mid1990s up to the approval of the national policy in2003 (15). In Sweden, public health is perceived
as a universally important subject, but it rarely
reaches the highest national policy level. It is thus
is difﬁcult to involve high-level political actors
in policy development and implementation.
The results showed that actors perceived the
problems differently, depending on their agenda
and interest. Politicians and experts had a highimpact on the formulation of intersectoral healthpolicy and policy goals. However, there waslittle focus on implementation plans, implyingthat political actors were not in agreement,
while experts sometimes expressed conﬂicting
evidence-based opinions on how to best
implement the policy. The formulated targets, atboth national and local levels, were limited withregard to suggestions for action and plans for
implementation. The intersectoral health policy
did not manage to open the way for involvementof actors in other policy sectors, and there waslack of clarity about responsibilities in relation to
the policy (15).

ThailandTangcharoensathien et al. reported on the
structures that Thailand has enacted under the
National Health Act since 2007 (16). The act
established a National Health Commission, chairedby the Prime Minister. The commission members
comprise one third multisectoral public policymakers; one third academia and professionals; andone third civil society organizations and private
sector entities. They convene an annual national
health assembly, as mandated by law. The assembly
has adopted several landmark resolutions, inparticular those requiring multisectoral action
for health. Capacity-building is needed at
individual, institutional and system levels to enablemultisectoral action for health. For example, thehealth literacy of individuals and communities
requires strengthening. It is also necessary to build
individual and institutional capacities to generate
evidence on the positive and negative health
implications of certain public and private sectoral
policies. The evidence should be translated into
multisectoral policy decisions through a transparent
process of participation and engagement byrelevant stakeholders, including government,
citizens and the private sector. Progress should bemonitored through regular reports, which should
be made publicly available. Effective multisectoral
action for health requires consensus across all
partners to reach a shared vision, which can beperceived as a common ground wherein each
institutional vision lies. The shared vision is based ontrust and respect; care should be taken to ensurethat it is not undermined (16).
UgandaZoonotic diseases continue to be a public healthburden globally. Uganda is especially vulnerable
due to its location, biodiversity and population.
Sekamatte et al. report on a One Health zoonotic
disease prioritization workshop that identified
multisectoral zoonotic diseases of greatest
national concern to the Ugandan Government.
The workshop was conducted in collaboration
with the Global Health Security Agenda (17).
Seven zoonotic diseases were identified aspriorities for Uganda: anthrax, zoonotic influenza
viruses, viral haemorrhagic fevers, brucellosis,
African trypanosomiasis, plague, and rabies.
One main conclusion of the prioritization wasthat a One Health approach and multisectoralcollaboration are crucial to the development andimplementation of surveillance, prevention andcontrol strategies for zoonotic diseases. Uganda

Key elements of multisectoral preparedness coordination

used such an approach to identify zoonosesof national concern. Identifying these priority
diseases enables Uganda’s National One Health
Platform and Zoonotic Disease Coordination
Office to address these zoonoses in the futurewith a targeted allocation of resources (17).
United Republic of Tanzania
Mghamba et al. described in their article thesuccess of the United Republic of Tanzania in
health security (18). The country was the first to
finalize a costed national action plan for healthsecurity following the joint external evaluation,and in doing so met the recommendationsof the IHR review committee. The planning
process involved all relevant authorities andlevels, including those outside the healthsector, and identified the need for a high-level
coordination platform to map stakeholders
and ensure collaboration between multiple
sectors. This platform ensures coordination
with other existing plans (including diseasespecific plans) at all administrative levels of thecountry. The goal of this mechanism is to limit
duplication in resource mapping and planningand maximize synergies with the National Health
Sector Strategic Development Plan. Moreover,a national coordination mechanism allows theUnited Republic of Tanzania to proactively
position available scarce resources from specificprogrammes into sectorwide development ofhealth systems capable of addressing all hazards,
and to streamline monitoring and accountability
without jeopardizing the ongoing objectivesof disease-specific programmes. Key guiding
principles that were critical to the developmentof the national action plan for health security
were country ownership of the entire process;high-level government commitment; use of
the One Health approach; and linking the plan
to national planning and budget cycles. The
multisectoral or One Health approach ensured
that the national action plan for health security is
an integral part of health system strengthening.
Additionally, the national action plan for healthsecurity was launched at a parliamentary
session in September 2017, ensuring thatparliamentarians are fully aware of the planand can advocate increased domestic funding,including from the private sector (18).

2526 Multisectoral preparedness coordination framework

Topics

Education

Brucellosis

Burgess et al. explored the relationship between
the health and education sectors in Australia(20). They recommended the collaborative
development of memoranda of understanding
between the different sectors, setting minimum
requirements and standards, and clearlydeﬁning roles and responsibilities to allow both
sectors to work more effectively together.
Establishment of clear communication channels
between sectors is also needed. It is importantto recognize that the organizational culturesof the health and education sectors differ
markedly, and the core values of both sectors
needed to be considered (20).

Brucellosis is a major cause of loss in livestock
production, but also represents a serious hazard
for public health as a zoonotic disease. Bögel,Griffiths and Mantovani report that in Italy the
implementation of control programmes was
supported by intersectoral collaboration involving
all concerned services, notably public healthand veterinary services, directly committed tobrucellosis control. In a health team approach,physicians, veterinarians and other health workers
coordinated their work from the planning stage
through implementation to evaluation of allphases, contributing to a decrease in incidence ofthe disease in humans and animals (13).
RabiesThe new operational protocol and practical
network of local key players from different
sectors involved in rabies detection,
reporting and implementation of appropriate
interventions in the Philippines was recently
established. It is initiated by recognizedtriggers, such as detection of confirmed orprobable rabies cases, and is closely linked withearly detection in animals, case investigation,
quarantine, diagnosis, reporting and postexposure prophylaxis. This tool has documented
success in initiating timely actions to laboratoryconfirmed rabies cases being investigated,which has saved many human lives (14).
Agriculture
Hawkes and Ruel have described a frameworkthat should improve the linkage between the
agriculture and health sectors (19). The framework
is intended to encourage researchers working at
the intersection of agriculture and health to cometogether to form a larger and stronger community
to increase the evidence base from which lessons
can be learned to solve linked problems. To
achieve this, the authors call for better compilationand communication of evidence of successes
and failures, and advocate capacity-building
and improved policy-making and governancestructures to facilitate linked approaches, startingby setting up forums to bring the stakeholders
together. Agricultural and health researchers
should identify and prioritize research gaps andneeds and develop a joint research agenda. All
stakeholders should invest in capacity-building todevelop comprehensive action on the ground (19).

Disaster risk management
In November 2012, the Regional Committee for
Africa adopted a comprehensive 10-year regional
strategy for health disaster risk management(DRM). This was intended to operationalize theWorld Health Organization’s core commitments
to health DRM. The study of Olu et al. reported
on the formative evaluation of the strategy,
including the progress achieved to date (21).
In total, 58% of the countries assessed had
established DRM coordination units within theirministry of health. Most had dedicated ministryof health DRM staff (88%) and national-level
DRM committees (71%). Only 14 (58%) of thecountries had health DRM subcommittees using
a multisectoral disaster risk reduction platform.
Less than 40% had conducted surveys suchas disaster risk analysis, hospital safety index,
and mapping of health resources availability.
Key challenges in implementing the strategy
were inadequate political will and commitment
resulting in poor funding for health DRM,
weak health systems, and a dearth of scientificevidence on mainstreaming DRM and disasterrisk reduction in longer-term health systemdevelopment programmes. Implementationof the strategy was behind anticipated targets
despite some positive outcomes, such as anincrease in the number of countries with health
DRM incorporated in their national healthlegislation, ministry of health DRM units, andfunctional health subcommittees within national
DRM committees. Health system-based,
multisectoral, and people-centred approaches
are proposed to accelerate implementation of
the strategy in the post-Hyogo Framework of
Action era (21).

Key elements of multisectoral preparedness coordination

Financing
McDaid and Park analysed financing
mechanisms to encourage intersectoralcollaboration (22). They conclude that there
is limited explicit discussion of this topic in
the literature. Three principal approaches
to financing for intersectoral collaboration
are described: discretionary but earmarked
funding, which usually remains under thecontrol of a ministry in charge of health;recurring delegated financing allocated to anindependent body; and joint budgeting between
two or more sectors. Positive examples of all
three financing mechanisms can be identified.
Their effectiveness in supporting intersectoralcollaboration depends on factors such asorganizational structures, management, culture
and trust. Imbalance in the financial andresource contributions from different sectors
can hinder implementation of an intersectoral
activity. A sense of ownership for each sector
is important for the successful collaborations
identified. To support policy-makers instrengthening or introducing specific policies
to support intersectoral collaboration between
health and other sectors, the following financing
mechanisms were suggested by the authors:earmarked funding, delegated financing
and joint budgeting schemes; legislation
and regulations that allow budget sharing
between agencies and ensure accountability;
identifying outcomes of interest to all potential
intersectoral partners within a partnership;routine effective monitoring and evaluation;
voluntary joint budgeting with appropriate
regulatory safeguards; and fiscal incentives andaccess to technical advice and support (22).
Human resources for health
Cameroon had a severe shortage of humanresources for health, and those that were available
were concentrated in urban areas. As a result of
the national emergency plan for 2006–2008,

innovative strategies and a multisectoral
partnership – led by the Ministry of Public Healthand supported by diverse national and internationalorganizations – were developed to address theshortages and maldistribution of human resources
for health in Cameroon. As a result, between
2007 and 2009, the number of active healthworkers in Cameroon increased by 36%. In the
improvement of human resources for health,strong leadership is needed to ensure effective
coordination and communication between the
many different stakeholders. A national processof coordination and facilitation can produce
a consensus-based view of the main humanresources for health challenges. Once thesechallenges have been identified, the stakeholders
can plan appropriate interventions that arecoordinated, evidence based and coherent (7).
Legal preparedness
Bullard et al. focus in their paper on legal
preparedness in the United States (23). Theysuggest identification and engagement of all
relevant traditional and newer partner sectors– including, for example, law enforcement andcorrection, the judiciary, the military, businessleaders, school officials and parent–teacher
organizations, emergency management,
non-profit organizations, and faith-basedorganizations. They also emphasize the needto educate each sector regarding its roles
and underlying legal authorities and potential
liabilities during a coordinated response to a
public health emergency. They underline theimportance of after action review and tabletop exercises, which must include review oflegal issues mediating effective response.
They also call for appropriate coordination
mechanisms (preparedness plans, memorandaof understanding, mutual aid agreements),
which should be developed and tailored to
sectors, partners, and anticipated cross-sectoral
involvement in emergency response (23).

2728 Multisectoral preparedness coordination framework

References: Annex 1
1. 	Axelsson R, Bihari-Axelsson S. Intersectoral
problems in the Russian organisation of
public health. Health Policy. 2005;73(3):285–
93 (https://www.ncbi.nlm.nih.gov/
pubmed/16039347, accessed 17 May 2020).

and Chronic Disease Prevention in Canada.
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gov/pmc/articles/PMC4910446/, accessed 17
May 2020).

2. 	Weick KE. Sensemaking in organizations.
SAGE; 1995 (https://us.sagepub.com/enus/nam/sensemaking-in-organizations/book4988, accessed 17 May 2020).

9. 	Holt DH, Carey G, Rod MH. Time todismiss the idea of a structural fix withingovernment? An analysis of intersectoral
action for health in Danish municipalities.
2018;46(22_suppl):48¬–57 (https://www.
ncbi.nlm.nih.gov/pubmed/29862907,
accessed 17 May 2020).

3. 	Magee M. Qualities of enduring cross-sector
partnerships in public health. American
Journal of Surgery. 2003;185(1):26–9(https://www.ncbi.nlm.nih.gov/pubmed/?t
erm=Qualities+of+enduring+cross-sector+
partnerships+in+public+health, accessed 17
May 2020).

10. 	Holt DH, Rod MH, Waldorff SB, TjørnhøjThomsen T. Elusive implementation:an ethnographic study of intersectoral
policymaking for health. BMC Health Services
Research. 2018;18(1):54 (https://www.ncbi.
nlm.nih.gov/pubmed/29378655, accessed 17
May 2020).

4. 	Shankardass K, Solar O, Murphy K, Greaves
L, O’Campo P. A scoping review ofintersectoral action for health equity involving
governments. International Journal of Public
Health; 2012;57(1):25–33 (https://www.ncbi.
nlm.nih.gov/pubmed/21931976, accessed 17
May 2020).

11.	Larsen M, Rantala R, Koudenburg OA, Gulis G.
Intersectoral action for health: the experienceof a Danish municipality. Scandinavian Journalof Public Health. 2014;42(7):649–57 (https://www.ncbi.nlm.nih.gov/pubmed/25074270,
accessed 17 May 2020).

5.	Rasanathan K, Bennett S, Atkins V, BeschelR, Carrasquilla G, Charles J et al. Governing
multisectoral action for health in low- andmiddle-income countries. PLoS Medicine.
2017;14(4):e1002285 (https://www.ncbi.
nlm.nih.gov/pmc/articles/PMC5404752/,
accessed 17 May 2020).
6. 	Lawless AP, Williams C, Hurley C, Wildgoose
D, Sawford A, Kickbusch I. Health in All
Policies: evaluating the South Australianapproach to intersectoral action for
health. Canadian Journal of Public Health.
2012;103(7 Suppl. 1):eS15–9 (https://www.
ncbi.nlm.nih.gov/pubmed/23618043/,
accessed 17 May 2020).
7. 	Kingue S, Rosskam E, Bela AC, Adjidja
A, Codjia L. Strengthening humanresources for health through multisectoral
approaches and leadership: the case of
Cameroon. Bulletin of the World HealthOrganization. 2013;91(11):864–7 (http://dx.doi.org/10.2471/BLT.13.127829, accessed
17 May 2020).
8. 	Willis CD, Greene JK, Abramowicz A, Riley BL.
Strengthening the evidence and action on
multi-sectoral partnerships in public health:an action research initiative. Health Promotion

12.	Salunke S, Lal DK. Multisectoral approachfor promoting public health. Indian Journalof Public Health. 2017;61(3):163–8 (https://www.ncbi.nlm.nih.gov/pubmed/28928298,
accessed 17 May 2020).
13.	Bögel, K, Griffiths R, Mantovani A.
Intersectoral collaboration in animal andhuman health. Annali dell’Istituto Superiore
di Sanità. 1992;28(4):445¬–50 (https://www.ncbi.nlm.nih.gov/pubmed/1303035,
accessed 17 May 2020).
14.	Barroga TR, Gordoncillo MJ, Lagayan
MG, Bernales R, Caniban M, Lopez E etal. Practical inter-sectoral linking: tool
to rabies One Health coordination to thegrass-roots level. Zoonoses and Public
Health. 2018;65(7):805–14 (https://www.
ncbi.nlm.nih.gov/pubmed/29978578,
accessed 17 May 2020).
15.	Mannheimer LN, Lehto J, Ostlin P. Window ofopportunity for intersectoral health policy in
Sweden open, half-open or half-shut? Health
Promotion International. 2007;22(4):307–
15 (https://www.ncbi.nlm.nih.gov/
pubmed/17947345, accessed 17 May 2020).
16.	Tangcharoensathien V, Srisookwatana
O, Pinprateep P, Posayanonda T,
Patcharanarumol W. Multisectoral actions

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for health: challenges and opportunities incomplex policy environments. International
Journal of Health Policy and Management.
2017;6(7):359–63 (https://www.ncbi.nlm.nih.
gov/pubmed/28812831, accessed 17 May 2020).
17.	Sekamatte M, Krishnasamy V, Bulage L,
Kihembo C, Nantima N, Monje F et al.
Multisectoral prioritization of zoonotic
diseases in Uganda, 2017: a One Healthperspective. PLoS One. 2018;13(5):e0196799(https://www.ncbi.nlm.nih.gov/
pubmed/29715287, accessed 17 May 2020).
18.	Mghamba JM, Talisuna AO, Suryantoro
L, Saguti GE, Muita M, Bakari M et al.
Developing a multisectoral National
Action Plan for Health Security (NAPHS)
to implement the International HealthRegulations (IHR 2005) in Tanzania. BMJ
Global Health. 2018;3(2):e000600 (https://www.ncbi.nlm.nih.gov/pubmed/29607098,
accessed 17 May 2020).
19.	Hawkes C, Ruel M. The links between agriculture
and health: an intersectoral opportunity to
improve the health and livelihoods of the poor.
Bulletin of the World Health Organization.
2006;84(‎12):984–90 (https://apps.who.int/
iris/handle/10665/269792, accessed 18 May2020).
20. 	Burgess T, Braunack-Mayer A, Tooher R,
Collins J, O’Keefe M, Skinner R et al. Optimizing
intersectoral collaboration between health andeducation: the Health Bridges study. Journalof Public Health. 2016;38(4):e430–7 (https://www.ncbi.nlm.nih.gov/pubmed/28158696,
accessed 18 May 2020).
21.	Olu O, Usman A, Manga L, Anyangwe S,
Kalambay K, Nsenga N et al. Strengthening
health disaster risk management in
Africa: multi-sectoral and people-centred
approaches are required in the post-Hyogo
Framework of Action era. BMC Public Health.
2016;16:691 (https://www.ncbi.nlm.nih.
gov/pubmed/?term=Strengthening+health+disaster+risk+management+in+Africa%3
A+multi-sectoral+and+people-centred+ap
proaches+are+required+in+the+post-Hyogo+Framework+of+Action+era, accessed 18
May 2020).
22.	McDaid D, Park A-L. Evidence on financing
and budgeting mechanisms to support
intersectoral actions between health,education, social welfare and labour sectors.
Copenhagen: World Health Organization
Regional Office for Europe; 2016 (https://apps.who.int/iris/handle/10665/326309,
accessed 18 May 2020).
23.	Bullard CH, Hogan RD, Penn MS, Ferris
HJ, Cleland HJ, Stier D et al. Improving
cross-sectoral and cross-jurisdictional
coordination for public health emergency
legal preparedness. Journal of Law, Medicine
and Ethics. 2008;36(1 Suppl):57–63 (https://www.ncbi.nlm.nih.gov/pubmed/18315754,
accessed 18 May 2020).

29

30 Multisectoral preparedness coordination framework

Annex 2. Expert roundtable:
development of a guide formultisectoral preparedness
coordination for IHR (2005)
To inform this guide, WHO regional offices
and WHO country offices selected countries toprovide examples of functioning multisectoral
coordination mechanisms for IHR (2005) or
health security in their country, which were
presented and discussed during a designatedexpert roundtable in Paris, 4–5 October 2018.
Bangladesh, Canada, Finland, France, Germany,
Ghana, Indonesia, Jordan, Nigeria, Romania,
Thailand, Tunisia, the United Kingdom of GreatBritain and Northern Ireland, the United Republicof Tanzania, the United States of America, Viet
Nam and Zambia shared their experiences. The
findings can be summarized as follows.
The coordination mechanisms in placein these countries mainly addressed IHR
implementation, diseases preparedness,
emergency services and outbreak responses,
as well as the collaboration between healthand armed forces or security agencies.
Several countries reported similar challenges.
For example, sectoral silos were emphasized
as posing a problem for the establishmentof multisectoral coordination mechanisms.
Different sectors had different perspectives,
responsibilities and priorities. The scarcity ofresources and competing interests were also
often identified as obstacles. It was found thatthe existing data in the different sectors weresometimes not comparable, making a common
understanding difficult. The time and work effort

that coordination required was also seen as adifficulty for its establishment.
Important factors for succeeding with theestablishment of multisectoral coordination
were the adoption of a regulatory framework
for coordination with clear chains of commandand the development of standard operatingprocedures and memoranda of understanding.
Joint situation assessments were an important
starting point for coordination. Joint trainings
and regular meetings were identified as positive
initiatives to build a common understanding
between sectors. The decision-making processes
should be transparent and traceable. It was
important to avoid unnecessary new structuresand duplications and to plan a regular budget line
for the coordination mechanism.
For the monitoring and sustainability of thecoordination mechanism, joint simulation
exercises, joint trainings and after action reviews
were recommended. It was also suggested thatthe intersectoral network be maintained beyond
the specific tasks for the purpose at hand. It
could be used to jointly mobilize resources andensure high-level political commitment.
The provided examples clearly identified abenefit in the establishment of multisectoral
coordination. It led in many cases to more
effective coordination, enhanced awarenessof the topics, and improved preparedness.
The mechanism resulted in more inclusive
communication and increased public trust in
the system. Overall it also helped to reduce
costs, if IHR capacity-building was embeddedin the system and not separated. In general, thecoordination mechanisms helped to establish
multisectoral engagement as a standard.

Key elements of multisectoral preparedness coordination

Annex 3. Tripartite zoonoses
guide and health emergency
and disaster risk management
framework
Tripartite Zoonoses Guide: a multisectoral,
One Health approach
The tripartite collaboration between the World
Health Organization (WHO), the Food andAgriculture Organization of the United Nations (FAO)
and the World Organisation for Animal Health (OIE)reflects a long-standing and successful partnershipin taking a One Health approach to address thechallenges to public health, animal health (bothdomestic and wildlife) and the environment
facing the world today. Prior to the 2019 Tripartite
Zoonoses Guide,1 only one jointly developed,
zoonotic disease-specific guidance document
existed: the 2008 tripartite Zoonotic diseases: aguide to establishing collaboration between animaland human health sectors at the country level.
A decade later, the tripartite collaboration
resulted in the creation of the 2019 Tripartite
Zoonoses Guide, an update and expansion of
the 2008 guide. The Tripartite Zoonoses Guide
covers prevention, preparedness, detection andresponse to zoonotic threats at the human–animal–environment interface in all countries and regions,and includes examples of best practices and options
based on the experiences of countries. Althoughfocused on zoonotic diseases, the 2019 guide isflexible enough to cover other health threats at
the human–animal–environment interface (forexample, antimicrobial resistance and food safety).
The Tripartite Zoonoses Guide provides countries
with guidance, best practices and tools for the
implementation of a multisectoral, One Healthapproach to address zoonotic diseases and othershared health threats at the human–animal–environment interface. The guide is for staff
managing governmental responses to zoonotic
disease threats. In most cases, this includes, at aminimum, the ministries responsible for humanhealth, animal health, wildlife, and the environment.
Nongovernmental sectors and disciplines not
represented in those ministries often need to be
included, such as partners or advisers.

Why a multisectoral, One Health approach?
Multisectoral means that more than one sector
is working together (for example, on a joint
programme or response to an event), but does not
imply that all relevant sectors are working together.
One Health approach involves multisectoralcollaboration but ensures that all relevant
sectors, including a minimum of the humanhealth, animal health, and environmental healthsectors, are engaged.
Benefits of a multisectoral, One Health approach•	All sectors understand their specific roles andresponsibilities and can collaborate effectively
for prevention, detection, and response to
zoonotic disease events and emergencies.
•	All sectors have the information they need.
•	Decisions are based on accurate and sharedassessments of the situation.
•	Accountability to each other and to decisionmakers ensures action by all sectors.
•	Regulations, policies and guidelines are realistic,
acceptable and implementable by all sectors.
•	Technical, human and financial resources are
effectively used and equitably shared.
•	Gaps in infrastructure, capacity andinformation are identified and filled.
•	Advocacy for funds, policies and programmes
is more effective.
Primary content areas of Tripartite
Zoonoses Guide
The Tripartite Zoonoses Guide has three primarycontent areas to support a One Health approachin countries:•	tools for understanding national context
and priorities for One Health, including
infrastructure mapping, stakeholder
identification, prioritizing zoonotic diseases
and country experiences;•	technical chapters for coordinated One
Health approaches that cover strengthening
government platforms for One Health,emergency preparedness, coordinatedsurveillance, investigation and response, joint
risk assessment, risk communication andworkforce development;•	operational tools for the guide, including aworkbook for strengthening government
platforms, a surveillance and informationsharing capacity-building guide, and a joint
risk assessment operational tool.

1 Taking a multisectoral, One Health approach: a tripartite guide to addressing zoonotic diseases in countries https://extranet.who.int/sph/docs/file/3524

31

32 Multisectoral preparedness coordination framework

Health Emergency and Disaster Risk
Management Framework
The WHO Health Emergency and Disaster Risk
Management Framework provides a common
language and a comprehensive approachthat can be adapted and applied by all actors
in health and other sectors who are working
to reduce health risks and consequences of
emergencies and disasters. The framework also
focuses on improving health outcomes andwell-being for communities at risk in different
contexts, including in fragile, low- and highresource settings. Health emergency anddisaster risk management emphasizes assessing,communicating and reducing risks across thecontinuum of prevention, preparedness, readiness,
response and recovery, and building the resilienceof communities, countries and health systems.
Drawing on the expertise and field experienceof many experts who contributed to its
development, the Health Emergency and Disaster
Risk Management Framework is derived fromthe disciplines of risk management, emergency
management, epidemic preparedness andresponse, and health systems strengthening.
It is founded on the following set of core
principles and approaches that guide policy andpractice: a risk-based approach; comprehensive
emergency management (across prevention,
preparedness, readiness, response and recovery);an all-hazard approach; an inclusive, people- andcommunity-centred approach; multisectoral andmultidisciplinary collaboration; a whole-of-healthsystem approach; and ethical considerations.
The Health Emergency and Disaster Risk
Management Framework comprises a set offunctions and components that are drawn frommultisectoral emergency and disaster management,
capacities for implementing the IHR (2005),
health system building blocks, and good practices
from regions, countries and communities. The
framework focuses mainly on the health sector,
noting the need for collaboration with many othersectors that make substantial contributions to
reducing health risks and consequences.
The success of the Health Emergency andDisaster Risk Management Framework relies on
joint planning and action by ministries of healthand other government ministries, the national
disaster management agency, the private sector,
communities and community-based organizations,assisted by the international community. At thecore of effective health emergency and disasterrisk management are efforts to strengthen acountry’s health system, with a strong emphasison community participation and action to build
resilience and establish the foundation for effective
prevention of, preparedness for, response to
and recovery from all types of hazardous events,
including emergencies and disasters.

Key elements of multisectoral preparedness coordination

Annex 4. Examples of regional
and international initiatives
supporting multisectoral
preparedness coordination
Oslo Ministerial Declaration:
foreign affairs collaborative actions
for global health
The Global Health and Foreign Policy Initiative
was launched in New York in September 2006 at
the instigation of foreign ministers from Franceand Norway. Also known as the Oslo Group,
this initiative involves seven countries withdifferent profiles, but which are all engaged inhealth action: Brazil, France, Indonesia, Norway,
Senegal, South Africa and Thailand.
Their objectives are to build the case for increased
prominence of global health in the international
agenda, to demonstrate how foreign ministers
and foreign policy could add value to healthissues of international importance, and to show
how a health focus could harness the benefits ofglobalization, strengthen diplomacy and respondto new thinking on human security.
In 2007, the seven foreign ministers issued theOslo Ministerial Declaration with an agenda forcollaborative actions by foreign ministers aroundthree main interconnecting themes: capacity for
global health security; facing threats to global healthsecurity; and making globalization work for all.
Capacity for global health security
Capacity for global health security includes thefollowing foreign policy-related elements.
•	Preparedness and foreign policy. This includes
collaborative actions by foreign ministers toplace health impacts at the centre of foreign
policy and development strategies, engage indeveloping a roadmap for actions in large-scaledisasters and emergencies, support national
disaster planning and development of criticalnational capacity for emergency preparedness,and strengthen the capacity of the United
Nations Secretary-General to assume acoordinating role in facilitating actions related
to foreign policy in emergency preparedness
and to identify critical gaps in capacity for
effective implementation of the IHR (2005).
•	Control of emerging infectious diseases

and foreign policy. This includes
collaborative actions to commit to the earlyand full implementation of the IHR (2005),
exchange experiences and best practices,
identify gaps in implementation, support andfacilitate WHO’s leadership role, and support
the mobilization of adequate resources.
•	Human resources for health and foreign
policy. This includes collaborative actions
to support the development of a global
framework for tackling the global shortage ofhealth workers, encourage the development ofbroad national plans for human resources forhealth, and respond to the need to train more
health workers and support health research.
Facing threats to global health security
The following measures to mitigate threats to
global health security are identified.
•	Conflict. Measures include collaborative
actions to recognize the potential of healthto initiate dialogue across borders and tospearhead the resolution of conflict, recognize
the potential of global knowledge networks,
support the evolution of a more consistent
approach for monitoring suffering in conflict
and war, and further develop the case for ahealth focus in post-conflict reconstruction.
•	Natural disasters and other crises. Measures
include collaborative actions supporting thework of the Office for the Coordination of
Humanitarian Affairs and the Central Emergency
Response Fund, ensuring that priority is given
to restoring a functioning health system,
and monitoring the equitable distribution ofaid, taking account of the specific needs ofcaregivers and marginalized groups.
•	Response to HIV/AIDS. Measures
include collaborative actions to take up
the challenges that HIV/AIDS presents
to trade, human rights, peacebuilding,and humanitarian action, commit to theinternational agreements and politicaldeclarations linking and monitoring thesecommitments, and call for improved anddisaggregated data collection on HIV/AIDS in
all countries.
•	Health and the environment. Measures include
collaborative actions to make the links between
environmental policies and global health visible
in foreign policy engagements, recognizethat the potential of biotechnologies to help
developing countries should not be eclipsed byotherwise legitimate security concerns, and give33

34 Multisectoral preparedness coordination frameworkfurther attention to the potentially very severe
consequences to health of climate change.
Making globalization work for all
Action to harness the benefits of globalizationneeds to be undertaken in the following areas.
•	Health and development. This includes
collaborative actions to give health top priority
in the national and international crosssectoral development agenda, strengthen theefficiency of global health initiatives, improve
national and regional research capacity andthe management capacity of public healthsystems, enhance the capacity for national andregional production of essential medicines,
honour existing financial commitments,
initiate innovative financing mechanisms,
and work together with the International
Monetary Fund and the World Bank.
•	Trade policies and measures to implement
and monitor agreements. This includes
collaborative actions to affirm theinterconnectedness of trade, health, anddevelopment, reaffirm commitment to theDoha Declaration on Trade-Related Aspectsof Intellectual Property Rights, and foster
the full implementation of flexibilities andexplore and leverage multiple and innovative
approaches to reduce price and improveaccess to essential medicines.
•	Governance for global health security
agreements. This includes collaborative
actions to support policies for global healthsecurity in foreign policy dialogue and action
arenas, establish broader and more coherent
national leadership for global health issues,recognize and affirm the WHO Secretariat
and the World Health Assembly as the main
arenas for global health governance, recognize
the role of the private sector, knowledge
networks, and civil society organizations, andcontribute to financing global health in waysthat do not undermine existing commitments
to development financing.

Pacific regionalism: a framework forsustainable development, economic
growth, strengthened governance andsecurity through a regional approach
Leaders of the Pacific Islands Forum in 2014
endorsed the Framework for Pacific Regionalismwith a Pacific vision calling for a region of peace,harmony, security, social inclusion and prosperity.

Forum leaders in 2017 endorsed the “Blue Pacific”
identity as the core driver of collective action
to advance this vision, seeking to recapture
the collective potential of the region’s sharedstewardship of the Pacific Ocean based on an
explicit recognition of a shared ocean identity,
ocean geography, and ocean resources.
Four principal objectives underpin the Frameworkfor Pacific Regionalism:•	sustainable development that combines
economic, social and cultural development inways that improve livelihoods and well-being
and use the environment sustainably;•	economic growth that is inclusive and equitable;•	strengthened governance, legal, financial andadministrative systems;•	security that ensures stable and safe human,
environmental and political conditions for all.
The framework sets out a number of ways inwhich ambitious and transformative initiatives
best addressed through a regional approach canbe identified. Governments of the Pacific, throughexisting ministerial- and official-driven processes,
are one important avenue. Another is the regional
public policy consultation process. Through thesemechanisms the framework provides a politicalplatform that enables forum leaders to assert
their collective sovereignty over the Pacific vision
into the future. The framework prioritizes theregional political agenda, and in doing so provides
all stakeholders with the opportunity to align theirstrategic direction and resources.
Regionalism can be expressed in several ways
under the framework, including regional
cooperation (regional agreements between
national governments) and economic andpolitical integration that can lead to sharedsovereignty, shared political and legal institutions,and increased flows of people, goods and capital.
Implementation of effective forms of regional
cooperation and integration is underpinned in theframework by an emphasis on greater politicaloversight and discussion by forum leaders aroundkey issues such as political settlements, pooled
resources and sovereignty, as well as an emphasison ensuring that focused political discussion takes
place that considers only issues best serviced
through a form of regionalism, and by promoting
a more inclusive approach to regional public policy
development, such as health security.