High Income But Poor COVID-19 Outcomes: The Contrasting Results of The Pre-COVID 19 Joint External Evaluation Assessment Tool in Measuring Countries’ Global Health Security Preparedness and Response Capacities

Background:The unprecedented global impact of the COVID-19 pandemic heightened the concern over countries' preparedness and response capacities for dealing with pandemics.One of the global assessment tools to measure these capabilities is the Joint External Evaluation (JEE), with 52 indicators in 19 technical areas, contained in WHO's International Health Regulations (IHR).Under the JEE, a higher score indicates a higher pandemic response capacity.Thus, we examined countries' pre-COVID-19 preparedness and response capacities in accordance with their pre-pandemic JEE score, and compared it with their income status and COVID-19 outcomes.Methods: We extracted pre-COVID-19 country-specific JEE reports for 95 countries and COVID-19 cases and deaths data from the World Health Organization's databases as of 31 May 2020 and 9 June 2023 respectively.We grouped the JEE countries according to the World Bank country classifications by income level.Multivariate regression analysis was performed to examine the relationship between JEE scores and countries' COVID-19 cases and deaths, after accounting for countries' income status according to the World Bank income classification of countries.Results: Among the 95 countries, 67 (71%) had limited or no capacity to respond to a health emergency such as a pandemic (JEE scores 2 and 1 respectively).The capacities varied substantially across countries with only 5% of the high-income countries having limited or no capacities (JEE score <3) compared to all (100%) of the low-income countries having the same (p<0.001).Importantly, there was a strong positive correlation between JEE scores and COVID-19 cases and deaths (rho coefficients, =0.72 and =0.66 respectively, both p<0.001).This finding challenges the conventional wisdom that higher income and higher JEE scores lead to better outcomes.In fact, high-and middle-income countries with higher JEE scores experienced higher cumulative COVID-19 cases and deaths compared to low-income countries (p<0.001),highlighting the need for a more nuanced approach to preparedness.Conclusions: The JEE is intended to reflect countries' capacity to prevent, detect and respond to health threats.The higher the JEE score a country has, the better its pandemic outcomes should be, in terms of cases and mortality.We examined the pre-COVID JEE of 95 countries, and found that higher-income countries tend to have higher JEE scores.However, when we compared countries' pre-COVID-19 JEE scores and income levels with their performance during the Volume 07; Issue 02 COVID-19 pandemic, the JEE scores seemed to contradict countries' actual performance.Many high-income countries with high JEE scores performed poorly, worse than lower-income countries.This highlights the need for health security preparedness assessment tools, such as the JEE, to be continuously reviewed in light of the COVID-19 pandemic, and on an ongoing basis following every major health security event.They need to be purpose-built and outcome-focused so that they can meaningfully assist countries to better prepare for future pandemics.