Evaluating Sri Lanka's malaria re-establishment prevention using IHR and JEE frameworks

The International Health Regulations (IHR) developed and approved by the World Health Organization (WHO) in 2005 provide an overarching legal framework that stipulates countries' rights and obligations in handling and managing public health events and emergencies that may cross local and international borders. Sri Lanka established an IHR Steering Committee in 2016 providing an opportunity to significantly enhance intersectoral collaboration and information sharing, thereby improving the health and health security of humans and animals. A Joint External Evaluation (JEE) of IHR core capacities was conducted in Sri Lanka in 2018 to assess the country's preparedness to meet IHR. The aim of this study was to investigate the preparedness of the country for maintaining prevention of re-establishment of malaria in terms of IHR criteria based on indicators considered in the JEE conducted in 2018.

The criteria (prevent, detect, respond and IHR related activities) in the JEE which were relevant for the prevention of re-establishment of malaria in Sri Lanka were reviewed. The assessment was done by the authors. The Delphi technique was used to provide the relevant evidence and to assign a score by consensus following the scoring system that was originally used by the JEE.

In the prevent domain, all subdomains obtained a score of 5 except for IHR coordination due to the unavailability of a functional mechanism for coordination between relevant sectors. In detect domain, many of the subdomains demonstrated sustainable capacity. However, further improvement was required in workforce development. In the response domain, emergency preparedness subdomain demonstrated the greatest need for further improvement especially in emergency operation centre capacities, procedures and plans which obtained a score of two, reflecting limited capacity. In the fourth subdomain, IHR-related activity, securing the ports of entry demonstrated capacity even though the systems were not sustainable. Other subdomains achieved the highest score.

This study demonstrates that the IHR framework provides an useful tool to assess the capacity of a country during PoR to sustain malaria-free status. This novel approach used for the first time, has demonstrated that Sri Lanka has the sustainable capacity for the prevention of re-establishment of malaria 12 years after elimination. It is proposed that a malaria-specific tool using an IHR lens be developed and an evaluation be conducted once in 5 years in countries with high receptivity and importation risk certified as malaria-free.