Implementing the 7-1-7 target to improve epidemic preparedness and response in Uganda
Early and effective response actions are vital to mitigate outbreaks and other public health events. The 7-1-7 target (7 days to detect, 1 day to notify and 7 days to complete early response actions) is a performance improvement approach for epidemic preparedness. 7-1-7 data were collected by rapid response teams and presented to stakeholders at National Task Force (NTF) meetings, Uganda’s primary outbreak coordination platform, in the days immediately after event detection. From October 2021 to December 2022, 7-1-7 data were collected for 13 ongoing events that were presented at NTF meetings as well as 29 lower-risk events for which the NTF was not convened. Among these 42 events, 22 (52%) met the 7-day detection target, 31 (74%) met the 1-day notification target and 19 (45%) met the 7-day early response target, with 10 (24%) meeting all 7-1-7 target components. Systems bottlenecks identified across the 42 events were consolidated, shared with stakeholders and integrated into Uganda’s National Action Plan for Health Security (NAPHS) Operational Plan. Of the 108 subactivities in the 2023 NAPHS Operational Plan, 17% aligned with recommended activities that emerged from 7-1-7 implementation. Uganda’s experience demonstrated that real-time 7-1-7 reviews improved ongoing public health responses and that synthesising 7-1-7 data across events identified recurrent systems bottlenecks that warranted prioritisation during NAPHS operational planning. We recommend that other countries adopt WHO’s 2023 guidance on incorporating the 7-1-7 approach into Early Action Reviews to improve their outbreak responses.
Recent experiences with COVID-19, mpox, Ebola, cholera and measles illustrate the increasing frequency of public health events globally.1 2 Uganda, located in the ecologically diverse Congo Basin, is susceptible to zoonotic spillover, including intermittent Marburg and Ebola virus outbreaks. Additionally, Uganda has experienced recurrent outbreaks of other infectious diseases, notably measles, rubella and malaria.3 4 To address these threats, the Uganda Ministry of Health (MOH) identified the need to strengthen disease surveillance and outbreak response as a priority objective in its 2020/2025 MOH Strategic Plan.5
As a signatory to the 2005 International Health Regulations (IHR), Uganda has been implementing the IHR monitoring and evaluation framework. Uganda conducted Joint External Evaluations (JEE) in 2017 and 2023 and submits annual States Parties Self-Assessment Annual Reports (SPAR) every year.6 7 These assessments are valuable tools to determine national pandemic preparedness and response capacities. However, the COVID-19 pandemic demonstrated the limitations of these assessments,8 leading experts to recommend assessing system capabilities to respond to real-world events.9 10
Uganda adopted this recommendation by piloting the 7-1-7 target for performance improvement, advocacy and resource allocation. The 7-1-7 target proposes that each suspected outbreak should be detected within 7 days of emergence, notified to public health authorities within 1 day of detection and that seven defined early response actions be completed within 7 days of notification.11 Real-world performance responding to outbreaks is compared against these targets, bottlenecks and enablers of timely performance are identified, and improvement actions are proposed to address those bottlenecks and improve future systems performance.
In this article, we recount how the 7-1-7 target was implemented in Uganda as a real-time performance improvement framework for strengthening pandemic preparedness. We describe the workflows and tools put in place to implement 7-1-7, share results and lessons learnt from the first 15 months of implementation (October 2021 to December 2022) and describe how Uganda has used results from 7-1-7 to prioritise financing of activities during operational planning.
Uganda launched the 7-1-7 implementation in October 2021 by selecting 10 of 68 public health events that occurred in 2020 and 2021 for retrospective review. The dates of 7-1-7 timeliness milestones as well as contextual information useful for bottleneck identification were abstracted from situation reports, outbreak investigation reports, electronic surveillance systems, end-of-outbreak reports and after-action review reports. Findings, previously published,12 were disseminated at a stakeholder meeting in February 2022. The utility of the process led stakeholders to agree to continue prospective implementation of the 7-1-7 approach.
Before initiating prospective implementation, 7-1-7 was introduced to the MOH leadership team, including the Director General of Health Services and the commissioner and assistant commissioners of the Department of Integrated Epidemiology, Surveillance and Public Health Emergencies. In addition, we identified and engaged key stakeholders involved in emergency management, including government ministries, departments and agencies, development partners, implementing partners and academia. We initially used a one-on-one approach to facilitate in-depth conversations to help stakeholders understand 7-1-7 and address their concerns.
The MOH decided that the national Public Health Emergency Operations Centre (PHEOC) should manage prospective implementation. In Uganda, the PHEOC is responsible for coordinating national outbreak preparedness and response activities and acts as an information and coordination hub during public health events. In addition, the national PHEOC has primary responsibility for oversight of rapid response teams (RRTs), including deployment briefings (terms of reference, deployment orientation, field logistics and safety). Project activities were facilitated with funding from Resolve to Save Lives to a local implementing partner (Infectious Diseases Institute, Makerere University). A single consultant was engaged to support 7-1-7 adoption as 50% of their scope of work to develop forms, tools, and templates and support activity coordination.
The national PHEOC determined that RRTs would be responsible for collecting 7-1-7 data. To integrate 7-1-7 data collection into existing workflows for emergency preparedness and response, an existing RRT report template was revised to capture the 7-1-7 timeliness milestones as well as bottlenecks and enablers of timely action. National RRT staff were trained over 2 days on this new template and on the 7-1-7 approach. Training incorporated the ‘5 whys’ approach to root-cause analysis13 to identify specific bottlenecks of detection, notification or early response that might later be addressed through improvement actions. Once training of national RRT staff was complete, RRTs were expected to submit reports to the PHEOC following every deployment, enabling Uganda to begin assessing its performance detecting and responding to new public health events against the 7-1-7 target.
Throughout the initiation period, brief sessions introducing and explaining the 7-1-7 target were incorporated into other stakeholder meetings (eg, One Health coordination meetings, surveillance partner meetings and conferences).14 This increased awareness of 7-1-7 across sectors and emergency management partner organisations working in Uganda.
The PHEOC selected National Task Force (NTF) meetings as the venue for stakeholder review of 7-1-7 data for suspected or confirmed public health events to identify the opportunities for performance improvement. NTF meetings are the primary coordination platform used after an outbreak is detected to determine what, if any, response actions are appropriate. NTF meetings are convened and coordinated by the PHEOC and co-chaired by the Director General of Health Services and the WHO representative. Attendees include experts from the PHEOC, other MOH departments, representatives from other ministries and external partners and donors, with attendance varying from 40 to 70 participants depending on the type of public health event. Meetings are held for any public health event that might warrant a national response and are typically convened in the days immediately after the PHEOC is notified of the event.
During NTF meetings, the PHEOC supports RRT members to develop a 15 min presentation using a standard template to review 7-1-7 performance for the ongoing event. The presentation, given by a designated NTF member, reports bottlenecks identified by the RRT and proposed actions to resolve those bottlenecks. This leads to a discussion to reach consensus on immediate actions that should be taken to improve the ongoing response, as well as identification and documentation of longer-term actions that should be taken to improve preparedness for future outbreaks.
Between October 2021 and December 2022, 7-1-7 performance for 13 high-risk events was evaluated at NTF meetings as they were ongoing, including yellow fever, Ebola, chemical poisoning, anthrax, a cluster of deaths of indeterminate aetiology, multidrug-resistant tuberculosis, respiratory syncytial virus and malaria outbreaks. For events determined at NTF meetings to require a national response, 7-1-7 presentations were typically updated and included in subsequent NTF meetings to discuss and resolve newly identified bottlenecks and follow-up on the status of improvement actions.
The Sudan ebolavirus disease (SVD) outbreak in September 2022 illustrates how 7-1-7 was used for real-time performance improvement during an ongoing response. 7-1-7 performance was initially presented at an NTF meeting held the day after outbreak declaration. By the end of the presentation, stakeholders had agreed to complete several immediate actions to address identified bottlenecks (table 1). The combined presence of government officials, partners and donors at the NTF meeting facilitated rapid implementation of improvement actions.
Sample bottlenecks and improvement actions identified through 7-1-7 implementation during the Sudan ebolavirus disease outbreak
For example, when preparing the SVD 7-1-7 NTF presentation, the case management team shared that a challenge to timely response was an isolation unit with inadequate sanitation facilities. During the NTF meeting, an immediate action proposed to stakeholders was the need to relocate the isolation unit at Mubende Regional Referral Hospital to a larger building in the hospital complex and for partners to allocate funding to improve sanitation at the isolation facility. MOH representatives agreed to relocate the isolation facility to a recently constructed hospital building, and partners agreed to allocate funding. On the fourth and eighth days following the outbreak declaration, 7-1-7 presentations for SVD were again included during NTF meetings, where the completion status of all immediate actions was reviewed, and additional immediate actions identified. From these three presentations, stakeholders also reached consensus on a list of longer-term actions that could improve Uganda’s preparedness for future outbreaks (table 1).
Uganda collected 7-1-7 data on 42 events detected between October 2021 and December 2022, including the 13 events presented at NTF meetings and 29 additional smaller events for which an NTF meeting was not convened. Of the 42 events, 22 were viral haemorrhagic fever (Crimean-Congo haemorrhagic fever, SVD, Rift Valley fever and suspected outbreaks testing negative), eight were vaccine-preventable diseases (measles and yellow fever), five were vectorborne or zoonotic diseases (anthrax, malaria and rabies), two were respiratory diseases (respiratory syncytial virus and multidrug-resistant tuberculosis) and five were other events (chemical poisoning in humans and disease in animals). One officer in the PHEOC maintained a Microsoft Excel database for consolidating 7-1-7 data, including dates of timeliness milestones, brief narrative descriptions and systems bottlenecks and enablers. Throughout 2022, regional PHEOC staff who oversee coordination of smaller outbreak responses received training on 7-1-7. Subsequently, the number of health regions capturing 7-1-7 data and submitting it to the PHEOC increased from three to seven by the end of 2022.
Among the 42 events, 22 (52%) met the 7-day target to detect, 31 (74%) met the 1-day target to notify and 19 (45%) met the 7-day target to complete early response actions, with 10 (24%) meeting all 7-1-7 targets. Disease categories with the highest proportion of events meeting the detection target were viral haemorrhagic fever (59%), vaccine-preventable diseases (50%) and respiratory diseases (50%). For notification, respiratory diseases (100%), viral haemorrhagic fever (82%) and other events (80%) had the highest proportion meeting the target. For completion of early response actions, viral haemorrhagic fever (59%) and respiratory disease outbreaks (50%) most often met the 7-1-7 target (table 2).
Proportion of events meeting the 7-1-7 target, October 2021 to December 2022
Following WHO guidance, in 2018 Uganda developed a 5-year NAPHS to guide implementation of health security-strengthening activities. Beginning in 2021, Uganda began developing 1-year NAPHS Operational Plans, a multisectoral process led by the Office of the Prime Minister which has previously been described,15 with a reduced list of prioritised activities for the coming year.
The 2022–2023 NAPHS Operational Plan was developed in September 2022. Uganda used 7-1-7 data to prioritise activities for the year by consolidating all identified bottlenecks and categorising them based on stage of occurrence (detection, notification and early response). These bottlenecks were then placed into one or more of eight categories,16 which were sorted based on frequency of occurrence.
A 2-day bottleneck prioritisation workshop was attended by 35 stakeholders, including officials from the MOH, Ministry of Water and Environment, Ministry of Agriculture Animal Industry and Fisheries, Office of the Prime Minister and non-governmental partners. Stakeholders initially proposed prioritising the three most common categories of bottlenecks that occurred during detection, notification and early response (table 3). They reviewed these common bottlenecks for prioritisation and proposed additional less-common bottlenecks until consensus was reached on a final list of prioritised bottlenecks. Ultimately, stakeholders deprioritised notification bottlenecks owing to strong 7-1-7 performance and prioritised two additional bottlenecks: underutilisation of surveillance data and inadequate community awareness about transmission and prevention of anthrax.
The most common bottleneck categories for detection, notification and early response
Stakeholders were divided into five groups based on JEE technical areas: surveillance; national laboratory system; risk communication; medical countermeasures and personnel deployment; and national legislation, policy and financing.7 Each group was assigned one or two prioritised categories of bottlenecks. For each bottleneck category, stakeholders reviewed each event where the bottleneck was documented and proposed recommendations and activities to address the bottleneck and improve Uganda’s health security. For example, for the bottleneck ‘shortage of medical countermeasures’, stakeholders recommended ensuring availability at all response levels and proposed two activities: (1) conducting a national stockpile needs assessment and procurement; and (2) prepositioning of commodities at regional nodes. After proposing activities, each group then reviewed the previous year’s NAPHS Operational Plan and 5-year NAPHS to determine if the proposed activities were included in these plans or were novel activities.
At the 2022–2023 NAPHS Operational Plan development meeting, priority activities identified from the 7-1-7 workshop were provided to technical area team leads to facilitate their integration into discussions of activity prioritisation for the operational plan. In addition to the proposed 7-1-7 activities, other inputs into the prioritisation discussion included incomplete activities from the prior year’s operational plan, the 2022 SPAR, After-Action Reviews and the 2018–2023 NAPHS. Of the 48 activities proposed through 7-1-7, stakeholder discussions led to the prioritisation of 15 activities for inclusion in the operational plan (14 as subactivities and one as an activity further divided into 5 subactivities). 12 of these 15 activities had previously been included in the 2018–2023 NAPHS or the 2022 NAPHS Operational Plan, while three were novel. Of the 108 total subactivities in the 2023 NAPHS Operational Plan, 17% aligned with proposed 7-1-7 activities.
Over 15 months of implementation, Uganda captured 7-1-7 performance for 42 events and reviewed 7-1-7 performance for 13 events in real time to improve ongoing responses. However, the proportion of events with detection, notification and response times meeting all 7-1-7 targets was low (24%). For viral haemorrhagic fevers, over 50% of individual detection, notification and response targets were met. Yet, although viral haemorrhagic fever event detection, notification and response metrics each fell within the target >50% of the time, only 32% of events met the full 7-1-7 target for all metrics. Moreover, none of the eight vaccine-preventable or five vectorborne or zoonotic events met the 7-1-7 target. Addressing the most frequently observed bottlenecks highlighted in table 3 by fully implementing the activities derived from 7-1-7 within the 2023 Annual Operational Plan shown in table 4 will support prompt detection, notification and response for these event types. We recommend that the Government of Uganda fully implement the activities derived from 7-1-7 within the 2023 Annual Operational Plan to support prompt detection, notification and response to these events. Given the wide gap in achieving the 7-1-7 target in Uganda among different event categories, we suggest that 7-1-7 could be a useful performance improvement tool to identify bottlenecks across disease types that can subsequently be addressed to improve preparedness. A previous report of 41 events from five countries, including Uganda, showed that only 27% of events met the full 7-1-7 target,12 suggesting that timely detection, rapid notification and early response to disease outbreaks remain a challenge in many countries. This report also identified a similar list of recurrent bottlenecks, for example, lab confirmation and availability of countermeasures were among the three most common response bottlenecks.
Proposed activities from 7-1-7 incorporated as activities or subactivities into the 2023 NAPHS Annual Operational Plan
7-1-7 provides a simple approach to continually evaluate the real-world performance of systems involved in public health event detection, notification and early response, as well as the interconnected performance of various health security system components. By evaluating performance against the 7-1-7 target in the days immediately following event notification, we were able to identify bottlenecks and actions needing urgent completion to improve the ongoing response. Reviewing these activities at subsequent stakeholder meetings helped develop a continuous cycle of transparency and accountability that facilitated prompt activity completion to strengthen preparedness and response decision-making.
Our results also demonstrate that 7-1-7 revealed systems bottlenecks that were not identified through existing components of the IHR Monitoring and Evaluation Framework.17 SPAR and JEE are useful assessments of country capabilities,18 but may not identify operational challenges.17 19 Intra-Action Reviews, After-Action Reviews and Simulation Exercises evaluate real-world or simulated system performance, but are time and resource intensive and thus infrequently conducted.20–22
We found that reviewing performance against the 7-1-7 target provided a comparatively simple approach to evaluate system performance. A strength of the 7-1-7 approach was that it reviews the integrated performance of all systems involved in outbreak detection, notification and response, which may identify challenges that might be missed through individual system assessments. Combining findings from 7-1-7 with existing IHR Monitoring and Evaluation Framework components improved Uganda’s 2023 Operational Plan, providing a data-driven approach to prioritise activities that addressed common implementation bottlenecks.
Uganda’s experience applying 7-1-7 for performance improvement demonstrates that implementation requires relatively limited additional resources. Informed by 7-1-7 implementation in Uganda and other countries, WHO has released guidance on conducting Early Action Reviews using the 7-1-7 target,23 and the 7-1-7 Alliance has developed the 7-1-7 Implementation Toolkit.24 These resources should further reduce the workload required for 7-1-7 adoption. Resources required to sustain implementation include sufficient staff to support 7-1-7 presentations and track the completion status of immediate actions during an ongoing event, consolidate 7-1-7 data into a database and conduct synthesis of 7-1-7 bottlenecks and improvement action items at least annually to inform national planning.
Several factors facilitated Uganda’s successful implementation of 7-1-7. First, our decision to conduct an initial landscape assessment of existing systems and workflows was critical. This informed our decision to select the PHEOC to coordinate 7-1-7 implementation, based on its ability to convene stakeholders and serve as the information management unit for data on public health events. Additionally, it identified RRTs as best positioned to collect 7-1-7 data based on existing workflows. The PHEOC director served as a champion for 7-1-7 implementation, advocating for buy-in from the broad group of stakeholders who ultimately contributed to 7-1-7 adoption. Additionally, engagement of a broad group of stakeholders with varied resources (including external partners) for 7-1-7 presentations at NTF meetings enabled prompt actions to resolve bottlenecks during ongoing responses.
Uganda’s next steps include continued subnational rollout of 7-1-7 to all regional PHEOCs. Subnational implementation will allow Uganda to apply the 7-1-7 performance improvement approach to additional small-scale or lower-risk public health events, providing additional opportunities to strengthen detection, notification and response systems. Ensuring that subnational implementation is accomplished in a low-cost and sustainable manner will be challenging; we plan to share our experiences with subnational implementation in the future. We also plan to develop national guidelines for 7-1-7 implementation, including at subnational levels. An additional next step is improving 7-1-7 data management by migrating data from Excel into Uganda’s new Event Management System, which offers more robust data protection and disseminated data access. Lastly, continued 7-1-7 implementation will improve ongoing responses and identify national-level bottlenecks that need to be addressed through the next 5-year NAPHS and future Annual Operational Plans.
Uganda’s experience implementing the 7-1-7 target for performance improvement demonstrates added value alongside existing components of the IHR Monitoring and Evaluation Framework. We found that real-time 7-1-7 reviews improved ongoing public health responses and that synthesising 7-1-7 data across events identified frequent systems bottlenecks that warranted prioritisation during operational planning. The integration of the 7-1-7 target into Uganda’s health security system serves as model for systems strengthening and continuous performance improvement in practice. With WHO’s release of Early Action Review guidance incorporating 7-1-7, we recommend that other countries adopt this guidance, routinely review performance against the 7-1-7 target, identify systems bottlenecks and take action to resolve bottlenecks and improve epidemic preparedness and response.
Data availability statement
Data are available upon reasonable request. Data can be made available upon request to the Ministry of Health, IM, at [email protected].
Ethics statements
Not applicable.
This work is determined to not be human subjects research according to 45 CFR §46.102(e)(1) by the RTSL Research Committee. The MOH national task force on epidemics and public health emergencies approved the Uganda 7-1-7 pilot, oversaw the conduct of the evaluation and adopted the 7-1-7 approach. The Director General of Health Services, through the Commissioner Integrated Epidemiology, Surveillance and Public Health Emergencies, provided written approval to publish this manuscript after determining it was not human subject research.
Acknowledgements
We thank the staff of the organisations that closely collaborated to conduct this work: Uganda Ministry of Health, Infectious Disease Institute, Uganda WHO Country Office, US CDC Atlanta and Uganda Country Office, and Resolve to Save Lives.
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