Aug 14, 2021 Volume 398 Number 10300 p559-640
7-1-7: an organising principle, target, and accountability metric to make the world safer from pandemics
Thomas R Frieden, Christopher T Lee, Aaron F Bochner, Marine Buissonnière, Amanda McClelland
COVID-19 makes it both possible and necessary to review lessons learnt from recent epidemics, re-evaluate approaches, and develop a framework that accelerates progress to make the world safer from epidemics. Every country and every community must be able to rapidly detect, report, and respond effectively to any potential major new health threat. Notably, wide variation in capacities exist across countries.1, 2 To improve early detection and rapid control of health threats, clear performance targets need to be set, cross-country variations need to be better quantified, factors responsible for these variations need to be identified, and speed and quality of detection and response need to be improved.3
Since the west Africa Ebola epidemic of 2014–16, several frameworks have been developed to measure readiness capacity. These frameworks focus on discrete components of health systems (eg, laboratory, surveillance4, 5 and universal health coverage6 ) rather than overall system performance, and do not adequately account for less easily measurable capacities, such as access to rapid financing and logistics, transparency, governance, leadership, or overall system fairness.7
How fast a system detects and responds effectively to a threat is the optimal measure of performance.8, 9 Continuously evaluating and improving timeliness can identify performance bottlenecks and help to accelerate progress, improving detection speed and response quality.8, 9, 10, 11 Timeliness metrics have been integrated into the WHO after-action review process 12 and the Triple Billion targets for its 13th General Programme of Work (GPW13).13 However, clear targets for time to detection and response have not yet been described. These metrics can supplement existing capacity measurements of the International Health Regulations (2005), including the Joint External Evaluation, which have been shown to be useful but not sufficient to predict effective response to COVID-19.2
The COVID-19 pandemic provides a galvanising moment to set clear and ambitious goals to promote accountability and to align stakeholders, including communities, countries, global health institutions, and donors. Ambitious but achievable goals are an essential communication tool to improve the identification and control of health threats. Establishing objectively verifiable benchmarks will give countries clear guidance, will give partners, civil society, WHO, and donors a clear pathway forward for measurement, accountability, and improvement, and will help governments and civil society to focus attention and resources.
Part of the reluctance to fund health preparedness stems from the absence of simple measurements of progress. One reason for broad support for the global initiatives against HIV and malaria has been the appeal, to politicians and voters alike, of clear metrics: the number of people treated, the bednets distributed, and the lives saved. For HIV, the 90-90-90 goal established by the UN 14 —ensuring that 90% of people infected with HIV know their status, 90% of those diagnosed receive sustained treatment, and 90% of patients receiving treatment have undetectable viral load—translated evidence of the benefits of antiretroviral therapy into targets for harmonised global action on solid, life-saving outcomes.15 Generating enthusiasm and support for a public health programme is easier if it has a performance metric that is straightforward, easily remembered, and will catalyse progress on the problem being addressed.
We suggest a new global target of 7-1-7 (panel) whereby every suspected outbreak is identified within 7 days of emergence, reported to public health authorities with initiation of investigation and response efforts within 1 day, and effectively responded to—as defined by objective benchmarks—within 7 days (appendix p 1). This 7-1-7 target can provide a global basis for accountability, be applied at country level to assess and improve performance, and can also be applied locally to promote equity in detection and context-appropriate response capabilities…