Organisational Capacity and Health Security

Evidence from Fighting Influenza A H1N1 Pandemics in 2009

In: Asian Journal of Social Science
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  • 1 Institute of Health Economics and Management ESSEC Business School

Despite the emphasis placed on response capacity building to strengthen health security in this region, no comparative data exists to look into the determinants that drive the capacity. For public and private managers, the ignorance of capacity development and failure to assess it, by and large, points to highly ambiguous and flawed methodological approaches. This paper therefore reports on a qualitative interview study into capacity building around health security and explains the emergence of response capacity against the fight of influenza A H1N1 pandemics in Singapore and Taiwan in 2009. This paper further provides empirically grounded evidence to identify prerequisites for capacity development towards health security in response to (the same type of) public health crises in Asia.

Abstract

Despite the emphasis placed on response capacity building to strengthen health security in this region, no comparative data exists to look into the determinants that drive the capacity. For public and private managers, the ignorance of capacity development and failure to assess it, by and large, points to highly ambiguous and flawed methodological approaches. This paper therefore reports on a qualitative interview study into capacity building around health security and explains the emergence of response capacity against the fight of influenza A H1N1 pandemics in Singapore and Taiwan in 2009. This paper further provides empirically grounded evidence to identify prerequisites for capacity development towards health security in response to (the same type of) public health crises in Asia.

Introduction

While the concept of human security was a convenient and useful way to promote a wide array of people-centred initiatives (UNDP, 1994), the way health security is defined currently has no universal agreement (Aldis, 2008; McInnes and Lee, 2006). The debate within human security lies in the definition, the scope and the very utility. The concept of health security faces the similar criticism.

As one of core issues in human security, health security deals with the defence of human life and personal integrity (Dorn, 2003). With wide but inconsistent use of the term among global health actors, the construct of “health security” has led to more confusion than ever in several fields of disciplines. As a result, social scientists often find themselves frustrated in sharing a common theoretical approach to study this complex, interdisciplinary issue. This challenge, as we argue, becomes more complicated if one fails to explore the attributes to health security.

Considering the difficulty in proceeding from any unified academic methodology, it is imperative to comprehend the construct of health security by providing more empirical evidence in order to ease the current state of confusion. The issue of disease outbreaks, among others, provides a legitimate and valuable venue of enquiry in this regard, both practically and theoretically (Ingram, 2005; McInnes and Lee, 2006).

Disease outbreaks and localised epidemics have long been recognised to have implications for health security at both the individual and the community level (Ansell et al., 2010; Rodier et al., 2007; UNDP, 1994). Health crisis events increasingly demonstrate that small, uncontrolled outbreaks are able to present a number of key security challenges to the society at all levels, threatening individual and community well-being. Though every disease is different in nature and behaviour, infectious diseases share several common attributes to health insecurity: they have the potential to disrupt various social sectors and critical health infrastructure, they adversely affect cross-sector jurisdictions, and they generate societal anxiety that undermines social functioning and cohesion.

Emerging infectious diseases (EIDs), in particular, have dramatically contributed to widespread human suffering and death, as well as adversely affecting the region’s economic and social security. This is exemplified in the event of the 2003 Severe Acute Respiratory Syndrome (SARS). After its outbreak in southern China, SARS subsequently spread to over 30 countries with over 8,000 cases of infection, of which 800 died—with the majority in Asia. The SARS epidemic horribly caused a large scale of social disruption in this region (Asian Development Bank Outlook, 2003). Similarly, the emergence of a new strain of H5N1 (influenza A) initially in Hong Kong and its subsequent spread across Asia, Europe and into Africa has (at the time of writing) resulted in approximately 600 human cases and almost 360 deaths (Garrett and Fidler, 2007). Through an array of public health measures, the disease outbreaks were eventually contained, and the health security was restored. However, the issue of infectious disease outbreak still remains a great challenge to this region that demands more academic inquiry into the attributes to health security. Most importantly, there remain unresolved, key questions: what organisational capacity leads to health security, and what is the relationship between capacity and security?

Despite the emphasis placed on organisational capacity building to enhance health security in this region, no comparative data exists to look into the determinants (or prerequisites) that drive the capacity amid public health crises. For sociologists in general and public health scholars in particular, the ignorance of capacity development and failure to assess it, by and large, indicates ambiguous methodological approaches to insecure contexts. It could be argued that without empirical data, policy makers have difficulty comprehending organisational capacity for promoting people’s security. And without adequate understanding of what capacity works and what not, public policy in favour of individuals’ security is barely established (Coupland, 2007). This paper, therefore, provides empirical data by reporting on a qualitative interview study into capacity building around health security at the organisational level, and explains the emergence of organisational response capacity against the fight of influenza A H1N1 pandemics in Singapore and Taiwan during 2009 and 2010.

This paper aims to provide empirically-grounded evidence to identify prerequisites for organisational capacity development toward health security in response to (the same type of) disease outbreaks in Asia. This paper has five parts. First, we briefly describe the H1N1 pandemic situations in Taiwan and Singapore retrospectively. Second, we propose an organisational capacity framework to investigate the determinants of health security among public health organisations. Third, we detail the methodology and data sources in this research. Next, we describe our analysis, findings, as well as implications, with regard to the determinants of health security amid public health crises, followed by a conclusion.

Summary of the H1N1 Pandemics in Taiwan and Singapore

In April 2009, H1N1 first broke out in Mexico and the USA. On 27 April, the WHO raised its pandemic alert level1 from Phase 3 to Phase 4, a phase “characterized by verified human-to-human transmission of an animal or human-animal influenza virus able to cause community-level outbreaks.” Two days later, the pandemic alert level was further raised to Phase 5, indicating that at least two countries in one WHO region had found cases of human-to-human transmission of the virus. Meanwhile, the WHO suggested all countries to “immediately activate their pandemic preparedness plans” and “remain on high alert for unusual outbreaks of influenza-like illness and severe pneumonia”. Within weeks, on 11 June 2009, the pandemic alert level was raised to Phase 6, denoting a worldwide pandemic, when sustained local transmission had occurred in general population across multiple WHO regions.

At the beginning stage of H1N1 outbreaks in Taiwan, the Centers for Disease Control (CDC) implemented border control in an effort to prevent or delay the spread of the virus from abroad. On 20 May 2009, Taiwan’s Central Epidemic Command Center (CECC) confirmed the first (imported) case of H1N1 influenza in Taiwan. The CDC immediately reported to the WHO and contact points in other countries through International Health Regulations (IHRs) Focal Points. Four days later, on 24 May, the first indigenous case was confirmed. The precautionary measures in public health control triggered a great deal of policy responses at different fronts in Taiwan. When the WHO announced in mid-June 2009 that the entire world was in the pandemic period of moderate severity, Taiwan swiftly transited to mitigation strategies. As many H1N1 patients could recover fully without medical treatment, the CDC soon modified the strategy of case management. In the pandemic development in Taiwan from 19 June 2009 to 8 May 2010, a total of 923 complicated cases were reported and confirmed, including 39 deaths (CDC, 2010). Taiwan successfully controlled the H1N1 pandemic in many ways. The mortality rate of H1N1 in Taiwan was 1.8 per million, one third of the average among Organisation for Economic Cooperation and Development (OECD) members and one-fifth of America’s average. Taiwan ranks among the top 5 countries globally for her island-wide vaccine coverage. Admittedly 25 per cent of the population in Taiwan, a cumulative total of 5.6 million people, received a shot against H1N1.

In Singapore, the Ministry of Health (MOH) elevated the country’s Disease Outbreak Response System from green to yellow2 on 28 April, soon after the WHO raised the pandemic alert level. One month later, the first case of H1N1 was detected at a local clinic on 27 May 2009. The case was subsequently sent to a local hospital designated to treat H1N1 cases. About three weeks after the first imported case, community transmissions (with no links to the first case) broke out at an alarming rate. Health authorities in Singapore immediately introduced rigorous containment measures, which eventually brought down the rate of community transmission. Most notably, at the peak of the H1N1 pandemic (from 26 July to 1 August 2009), community outpatient clinics attended to nearly 24,477 cases for acute respiratory illness. In the week between 2 August and 8 August 2009, 65.5 per cent of influenza-like cases were confirmed to be H1N1. By September 2009, there were 1,348 confirmed cases of H1N1 in Singapore. Singapore practiced in-hospital quarantine measures for the first wave of infected cases. In early November 2009, effective vaccines against the H1N1 pandemic began to be available to the local community. Although the WHO later categorised the H1N1 pandemic as one of moderate severity, the public health control measures introduced to mitigate the severity of this pandemic undoubtedly contributed in no small part to contain this highly contagious pandemic. Table 1 provides a comparison of H1N1 pandemics situation in both countries.

Table 1Comparison of H1N1 pandemics in Singapore and TaiwanTable 1

The Organisational Capacity Approach

Using a capacity approach to explore the determinants of health security in top public and private managers’ understanding, we need to understand what capacity is most frequently referred to in the context of infectious disease outbreaks. In such context, capacity building at the organisational level has a close relationship positively with surveillance systems and surge capacity in place for outbreak responses (Aledort et al., 2007; Briand et al., 2011; Coker and Mounier-Jack, 2006; Feldbaum and Lee, 2004; McInnes, 2004; WHO, 2001; WHO Writing Group, 2006; WHO, 2009).

At the outset of 21st Century, the WHO in particular mandated member states to engage actively in improving epidemic alert and response measures (WHO, 2001). It is widely accepted that evidence driven information from surveillance is necessary to better inform policy makers about what works and what fails (McInnes and Lee, 2006). To maintain health security at the individual and community levels, one needs to focus mainly on having a disease surveillance system for outbreak responses, through which new outbreaks will be rapidly identified and resources mobilised effectively to mitigate adverse health effects. Disease surveillance systems refer to an epidemiological monitoring that aims to establish patterns of progression. Surveillance systems help anticipate, contain and mitigate risks that are detrimental to health security.

In particular, the capacity building of surveillance system serves three critical functions before and during disease outbreaks. Firstly, it provides a wide-net approach to identify all suspicious cases as early as possible for isolation; secondly, it may provide advance warning and detection of impending outbreak events; and thirdly, surveillance indirectly lowers the mortality rate through better understanding of the health extreme conditions (Briand et al., 2011). At the individual level, disease surveillance of the pathogenic agent is extremely helpful in preventing the spread of the disease from one to another person. It is also imperative to enhance health security by extending surveillance system from individuals to the community level, and this invariably requires close partnership between the local health authorities and healthcare professionals, such as general practitioners, infectious disease specialists and laboratory scientists at hospitals (Wertheim et al., 2010). However, surveillance systems cannot function effectively to maintain health security if surge capacity is lacking.

Surge capacity matters to health security because it pertains to allocating healthcare facilities and stockpiling issues; for example, logistics allocation, which includes the acquisition, storage and distribution of medical supplies and other items. Without the surge capacity in place, it is not possible for public health organisations in this region to deal with extreme adverse health events (WHO, 2010). In the context of preventing disease outbreaks, surge capacity is perhaps the most visible component of epidemic resources that can save many lives when managed well. Surge capacity refers to resources and medical facilities to support health security at various settings.

In practice, resources include skilled human resources (e.g., medical staffing, nurses and respiratory therapists) and stockpiles (e.g., personal protective equipment, vaccines and antivirals) whereas medical facilities denote hospital beds, medical diagnostics, therapeutic equipment and supplies. During public health crises, the consumption of protective material, such as personal protective equipment (PPE) or antivirals, and the demand for healthcare workers would mount 200 to 300 times. Crucially, a shortage of highly skilled healthcare workers and stockpiles is a major hurdle in the preparedness planning and response, and has thus stifled capacity development in detecting, assessing and responding to emerging public health threats (Krumkamp et al., 2011). Surge capacity also concerns the ability to mobilise management systems, supplies and equipment, as well as development and allocation of resources to meet a surge in demand for medical services.

Methodology and Data Sources

As we set out to explore top public managers’ understanding of response capacity development in a variety of national and organisational contexts within the 2009 H1N1 pandemics in Singapore and Taiwan, we undertook a mixed-method research design, including comparative case studies, a qualitative analysis of interview statements and documents (media reports, official documents and evaluation notes).

We enlisted the help of leading national public health organisations in each country (i.e., the Centers for Disease Control in Taiwan’s case and Communicable Disease Division in Singapore’s Ministry of Health), each recommending the major players within the broader network of disease control and prevention. We identified 35 potential interviewees across various organisations that were invited for interviews. We ensured a fair representation across medical and non-medical professionals, as well as managerial responsibilities. Eventually, we gathered primary data through 30 research-administered, face-to-face interviews from 20 organisations: 20 informants from 12 organisations in Taiwan’s communicable disease network and 10 from 8 organisations in Singapore (see Table 2). The remaining five invited to participate either did not reply or declined our interview request.

Table 2List of organisations in our studyTable 2

Face-to-face interviews, though slower and more costly, have the best reputation for response rates. All the organisations that we chose in this study were responsible for managing the 2009 H1N1 pandemics. The interviews in Taiwan were conducted between June and August 2011, whereas the interviews in Singapore between March and May 2013. Each interview took between 45 minutes and one hour, and was audio-taped with permission. All interviews were transcribed (except in two instances where the audio recorder failed to function).

We content analysed the interviews and used the interviewees’ statements as evidence to support or contest the theoretical framework. Descriptions of informants are provided alongside illustrative quotes in the findings section. Our approach followed the tradition of thematic analysis (Miles and Huberman, 1994), which informed the development of a coding framework based on research questions, existing literature and interview data refined and applied to transcripts. Each factor was evaluated based on the narrative of 30 in-depth interviews, supported by secondary data from government and non-government documents.

The public health crisis, though taking place in different countries, triggered a great deal of community response and capacity development. The leading public health organisations in each country represented one of the few public organisations that frequently encounters and deals with public health crises. It could lend itself as a qualitatively different kind of public organisation for delivering complex public services across various interested sectors. Our study adopts case study and descriptive methods that are often used in conducting the research of crisis management (Comfort and Kapucu, 2006; Moynihan, 2009). The case study approach is particularly useful because it focuses on a development process of certain key response capacities through major medical emergency events, and provides unparalleled detail of governance arrangements. It also details a dynamic setting with considerable variations in how (the same) pandemics were handled across countries.

Analysis and Discussion

Surveillance Systems

Our study shows that having a prehistory of fighting SARS epidemics drives both Taiwan and Singapore to boost the response capacity respectively in the following ways.

Drawing heavily on its experience with SARS’s wide-net surveillance, Singapore’s Ministry of Health (MOH) introduced a number of novel surveillance measures to integrate epidemiological data and to identify the emergence of a new virulent strain faster. For example, a rigorous measure of thrice-daily temperature surveillance of all healthcare workers was introduced by MOH in every institution, as well as active surveillance for clusters of febrile patients (Goh et al., 2006). These novel measures were embraced by the public given the high level of trust they have towards formal institutions. One informant responded,

In general, every public health control measure introduced by Singapore’s health authorities was well-received by the public for two main reasons: Firstly, the level of trust Singaporeans had for their government was relatively high and support for the party in office was strong. Secondly, most Singaporeans have a strong belief in the government institutions that are able to deliver public services, based on the track record.

Director, Ministry of Health, Singapore

Similarly, the past experience of SARS reminded Taiwan’s CDC of the importance of implementing a nation-wide health intervention in epidemics. To achieve this end, our evidence indicates the CDC collaborated with a wide range of key individuals from various organisations to consolidate different information links. Information links in disease control transmit key epidemiological information, which has the potential to elucidate many important issues across various needs, concerning the behaviour of this pathogen in humans, and how it may be controlled.

One of the most important lessons that are learned from the fighting SARS was the significance of establishing sound surveillance systems.

Director-General, Centers for Disease Control, Taiwan

At this period in particular, Taiwan’s CDC applied multifaceted communication strategies to strengthen its information links with government agencies and medical professional associations. For example, before the H1N1 virus broke out, the CDC began to work closely with the Council of Agriculture for the surveillance and quarantine of animals, food and agriculture continuity in chicken farms and traditional wet markets in response to the potential avian influenza. Admittedly, such a high level of vigilance in the disease control network resulted from the prehistory of fighting SARS. A high-level public health official from the CDC commented,

SARS provided us a chance to revisit the existing collaboration structure and resources, and generate an accumulation of new information for actionable plans.

Director, Epidemic Intelligence Centre, Centers for Disease Control, Taiwan

Our study shows the surveillance system in both countries tapped on web-based information technology (IT) to strengthen health security at the organisational level. Such web-based IT facilitates healthcare organisations, health authorities and academic institutions to make use of the systematic data more effectively on an integrative user-friendly interface. For example, during the H1N1 pandemics, the IT advances enabled Taiwan’s health authority to collaborate with a group of service providers (e.g., contract-laboratories, hospitals, sentinel physicians, local health authorities and government agencies) in the surveillance systems to monitor the disease. Another good example of functional surveillance systems is addressed below:

Each surveillance system in Singapore was designed in such a way that worked for different disease scenarios in different healthcare settings.

Director, Communicable Disease Centre, Singapore

At the same time, the CDC revamped its disease surveillance system by lifting the Sentinel Surveillance System at the end of 2009, and integrating with more advanced and more precise surveillance systems, e.g., databases of the National Health Insurance (NHI), Real-time Outbreak and Disease Surveillance (RODS) (Chen et al., 2010).

The integrated systems also worked for the person at the local health authority and medical care organisations. Given an identification code and password, the person in charge of disease control and prevention could immediately access the real-time data regarding disease surveillance and control online. For the general public, the integrated information platform provided them the recent aggregate data on the trend of a certain disease and case number from the CDC official website. The website-based information platform thus provided each partner with timely and valid data on available resources throughout the disease control efforts.

The platform enabled us to timely access to information, and upload surveillance results on a regular basis.

Director, Department of Health, Taipei City

This made epidemiological information transparent and widespread among all stakeholders. One informant also responded to this advance on information platform,

Each infection control authority was able to get an immediate online access to the information warehouse for more effective and prompt disease control … [the information] in fact helped our local partner face the epidemic with more confidence, and had more trust in the CDC.

Senior Medical Officer, Centers for Disease Control, Taiwan

Extreme adverse health events pose a great challenge to the current fragmented epidemiological surveillance system. In Singapore, one of the MOH’s notable innovations was the establishment of an Infectious Disease Alert and Clinical Database system to integrate critical clinical, laboratory, and contact-tracing information with a new information technology infrastructure developed to support the surveillance and management of emerging infectious disease information. Such inter-departmental information exchange platform was supported by modern cutting-edge information communication technology on the disease control frontlines. This platform was an information framework consisting of prior existing systems and newly-added systems.

The platform was a multi-level communication interface where multiple parties and stakeholders could report, update, retrieve and convey timely and relevant disease information on a common channel in an open fashion.

Director, Communicable Disease Division, Ministry of Health, Singapore

Having first-hand information was critical in disease surveillance at the early stage of the H1N1 influenza outbreak when the world knew very little about this emerging disease. In Taiwan’s case, being a focal point in the International Health Regulation (IHR) framework played a critical role in achieving health security. Taiwan joined the IHR framework in January 2009. With key information from the IHR framework, the CDC obtained timely access to the epidemiological data, followed the WHO’s advice, and activated a national influenza pandemic response plan. One informant from the local health authority commented on the importance of obtaining the key information,

During the H1N1 battle we were able to obtain latest epidemic data from IHR network, developing responding strategies and action plans. The battle proceeded almost as planned in advance.

Department Director, Kaohsiung City Government, Taiwan

Surge Capacity

Pressured by the public for its inability to deal adequately with SARS epidemics due to poor and insufficient epidemic resources and logistics allocation, the health authorities in both Taiwan and Singapore revisited the epidemic response systems and enhanced their surge capacity through the following measures.

First, a coordinating structure was formulated. In Singapore, a special taskforce of health professionals skilled in field epidemiology, informatics and monitoring and evaluation was stipulated. Such governance structure presented a joint effort made up of key policy makers, public health practitioners, senior clinicians and infectious disease specialists, and is headed by the Permanent Secretary of Health to coordinate resources allocation and streamline manpower supplies. Further investments in public health laboratory capacity came along with the coordinating body. The main benefit of this abridged command and control structure was that it dramatically shortened response time in resources distribution across various healthcare sectors during the 2009 H1N1 pandemic.

The taskforce is beneficial for greater collaboration and consensus building among partners.

Senior Manager, National Environment Agency, Singapore

The MOH also revised the Flu Pandemic Response Plan to include the primary healthcare providers, who could be called upon in case of a sustained community transmission in Singapore. This revised framework, the Pandemic Preparedness Clinics (PPCs) that includes 800 clinics in Singapore, also allowed all PPC doctors to undergo training seminars and workshops to update themselves on protocols and practices, such as N95 mask fitting, and to manage the flow of resources (Tay et al., 2010).

Similarly, in Taiwan, the CDC leader took the initiative to explore the possibility of having more authority in allocating infectious disease resources. With strong political support directly from the Central Government, the CDC subsequently underwent a reorganisation in which a specific Division on Resource Management was instituted in July 2004 (CDC, 2004). In this way, the CDC was in charge of planning and executing storage (stockpiling), logistics, inspection (stocktaking) and transportation of prevention materials. In response, the CDC acted swiftly to release a total of four million stockpiles of surgical masks. As a result, the panic during SARS caused by a shortage of masks did not happen dring the H1N1 pandemics.

When the general public and healthcare personnel could access masks with ease, the “oral mask” was not likely to become an issue—a lesson we learned from the outbreak of SARS in 2003.

Deputy Director, Centers for Disease Control, Taiwan

Second, a flexible virtual contract was developed with supply contractors to ease the cost of stockpiling or resell stockpiles back to other industries at a lower price. The major contractors have agreed to activate additional product lines so as to accommodate surge demands during an epidemic. To streamline logistics, our study finds it important to institute an inventory system for stockpiles of protective equipment. The system must be designed in such a way that stocks held both outside and inside of healthcare institutions can be promptly accessed and released to reduce a waste of resources during times of urgency. This measure enhances surge capacity in promptly mobilising resources based on needs assessment and information. The health organisations therefore have more autonomy in resources aggregation and distribution. In early May 2009, when the H1N1 outbreak became increasingly of concern, public panic in most countries led to an increased demand for facial masks.

To meet a surge demand for epidemic materials, we signed an agreement of priority order placement between the health authorities and its major contractors.

Infectious Disease Specialist, National University Hospital, Singapore

Third, boosting surge capacity needs a legal standing. In Singapore, the Infectious Disease Act (IDA) made it legally permissible to enforce mandatory health examination and treatment, exchange of medical information and cooperation between healthcare providers and the MOH, and quarantine and isolation of H1N1 patients. Therefore, it was a mandatory task for health organisations to legally stockpile antivirals in coping with the need of a major influenza outbreak in accordance with Influenza Pandemic Preparedness Plan, the highest guiding principles for influenza pandemic preparedness.

In Taiwan, given a legal basis from Communicable Disease Control Act (CDCA), health authorities had sufficient and persistent storage of PPE even before the H1N1 pandemics. In particular, adequate amounts of procedure masks (e.g., N95 masks, protective masks) were stored for the use of healthcare workers at the time of the pandemics. Our study shows that the CDC managed a consistent stockpile of surgical masks and N95 masks during these years. For example, the CDC managed to stockpile nearly 10 million of surgical masks in the warehouse.

With regard to antivirals, there were government budgets in place to procure sufficient amounts of them from abroad. The CDC had stockpiled varied amounts of antivirals to treat seasonal flu even before the H1N1 pandemic struck Taiwan. With government budgetary support, the CDC had a stockpile of influenza antivirals for approximately 2.3 million shots in stock, equivalent to ten per cent of the total population in Taiwan (Taipei Times, 2009).

As the CDC announced more indications for prescribing antivirals covered by the National Health Insurance Scheme and more flu clinics were available to the general public, there was an increase in demand for antivirals. Through the scheme, H1N1 patients obtained Tamiflu (Oseltamivir). The antivirals were initially distributed to major hospitals, especially to tertiary referral hospitals. After that, stockpiles were later distributed from the central government to other hospitals at the district level. In this way, public accessibility to the drug and treatment increased, which in turn attained health security at the individual level.

Implications

Crucially, our cases describe a positive relationship between organisational capacity and health security in both Singapore and Taiwan. We further illustrate the importance of having adequate response capacity, i.e., surveillance systems and surge capacity, in implementing control measures to maintain health security. However, our paper involves public health organisations in response to transnational disease outbreaks in Singapore and Taiwan where health infrastructure and systems are more advanced in the region. Hence, our research findings may not directly apply to countries with highly constrained resources. We also understand that maintaining health security is multi-factorial and enhanced response capacity in public health organisations alone should not be allowed to fully explain the success in containing disease outbreaks. Recognising the research limitation in its application, this paper deliberately proposes implications for the concept of health security, and human insecurity in general, in three ways.

First, a lack of resources in surge capacity remains a key issue in security planning which has dwarfed the capacity building in detecting, assessing and responding to emerging public threats. For lead public health organisations, without the adequate health resources in place, it is rarely possible to deal with security issues. Threats to health security are greater for countries with very limited resources and poor infrastructure due to insufficient access to health services, medical facilities and other basic necessities. The reason why sufficient surge capacity is important to health security, as our cases illustrate, is because health crises place considerable demands on those professional healthcare workers and security materials. For example, there is a problem of potential manpower shortages resulting from absenteeism among existing workforce at the time of a disease outbreak. Additionally, dealing with a health emergency situation, unlike natural disasters, often spans over a prolonged period of time. Working in such a crisis situation inevitably is challenging and stressful. Therefore, a response organisation needs to have adequate number of staffs and material resources to cope with a surge of security service demands.

Second, while the task of outbreak control implies the demand for collaboration among various sectors, it is not so obvious on what terms they might collaborate. Our study shows abundant resources without synergy may further undermine collaborative efforts in keeping health security coherent. As our cases indicated, when different stakeholders, such as the Ministry of Economic Affairs and Ministry of Transportation, brought their resources to the frontline, they actually complicated the process to maintain security due to the lack of synergy. This has been seen in the fight of SARS, for example, when many protective masks were withheld at the airport checkpoint awaiting administrative approval, but the general public were panicked for insufficient supply of masks. To achieve synergy in resources allocations and needs assessments, it is critical to: (1) highlight the health impact of people’s insecurity on the security agenda (Coupland, 2007), and (2) to ensure health authorities, such as the CDC and the MOH’s Communicable Disease Division, are equipped with the necessary skills and administrative discretion to achieve collaborative advantage in maintaining security. This is also where response capacity comes in to narrow the gap between national and international security capabilities. It calls attention to attributes of organisational capacity that serve the purpose of protecting individuals and communities from human insecurities.

Third, it is generally agreeable that human security relies on the exercise of conventional state forces for the protection of individuals (to be free, safe and secure) and emphasises the welfare of ordinary people. However, the evidence in our study suggests that draconian government measures, such as quarantine and travel restrictions, amid public health crises are less effective in maintaining health security than voluntary measures at the individual level (such as good personal hygiene and the voluntarily wearing of respiratory masks), especially over the long term. This, in fact, reflects the reality of the everyday experience of insecurity in different parts of the general public. Hence, collaboration between the national, local and individual levels is mandatory in order to foster better policy responses.

Therefore, promoting social responsibility is crucial in terms of slowing the pace of infection through good personal hygiene in all settings (Aledort et al., 2007; Bruine et al., 2007). In large part, this is closely related to organisational capacity in doing public education and risk communication. Indeed, getting the right message across to the general public can often be a major challenge amid crisis. To keep intact health security at the individual level, it is absolutely necessary for health authorities, together with agencies of communication and information, to disseminate essential information to the target population in a transparent manner. Our paper shows the advantage of having an established and respected organisation, such as a taskforce committee, that can act as the central authority for information collection and dissemination in this regard.

Conclusion

This paper has demonstrated that human security does not do away with state security, as the government’s capacity building initiatives to fight infection diseases is fundamental. However, we argue in this paper the issue of capacity building emerges as the first priority in the field of health security at the community and individual levels. To prove this argument, our study provides empirically grounded evidence to exemplify the significance of surveillance systems and surge capacity among different sectors that seek full public participation.

Another important point notes by this research is the importance of a multilevel collaboration between the regional, national, local and individual levels when formulating policy responses to human security threats. State officials and medical officials should take into consideration peoples’ experiences on the ground as the public’s experience on the allocation of resources and services is important in order to match the demand side with the supplier side.

Finally, this paper helps academics in human insecurity understand what health security means for decision makers who focus on investing in critical organisational response capacities and institutional arrangements. In terms of capacity building in the design and implementation of health policies, the insights drawn from our study are particularly useful both from a practical as well as a research perspective. Indeed, beyond adding to the body of knowledge on this subject, these insights also serve to guide the planning of health policies in promoting health security on a large scale.

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1

The WHO has set up the global pandemic-alert level from Phase 1 to 6. Phase 1 means “no viruses circulating among animals have been reported to cause infections in humans”, Phase 2 refers to “an animal influenza virus is known to have caused infection in humans”, Phase 3 denotes “an animal or human-animal influenza virus has caused sporadic cases or small clusters of disease in people, but there have not been community level outbreaks”, Phase 4 means “a reassortant virus is causing community-level outbreaks”, Phase 5 describes “human-to-human spread of the virus into at least two countries in one WHO region”, and Phase 6 refers to a global pandemic, which means there are community-level outbreaks in at least one other country in a different WHO region.

2

Singapore’s health authority uses five colours for different levels of disease outbreak. Green is equivalent to Phase 1 in WHO’s alert levels, yellow is Phase 2, orange is Phase 3, red is Phase 4 and black denotes Phase 5.

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