7-1-7 Implementation Toolkit

Champions are government stakeholders who can lead change management, such as individuals with leadership responsibilities for surveillance, response and/or preparedness planning. Although 7-1-7 implementation should not be burdensome, it may require workflow adjustments, new tools and additional responsibilities for some staff. Experience has shown that 7-1-7 implementation is more likely to result in improved epidemic preparedness with the buy-in of at least one champion who can:

• Advocate for 7-1-7 implementation;
• Provide high-level oversight;
• Initiate stakeholder mapping and engagement;
• Convene stakeholders to review progress towards goals;
• Elevate high-level findings and priorities emerging from 7-1-7 implementation for the attention of leaders.

Once potential champions have been identified and introduced to the 7-1-7 approach, it will be important to assess their interest, and if possible, secure a commitment to support implementation of a pilot project.

After the identification of a champion(s), early input should be obtained from a broad group of stakeholders capable of contributing to achievement of the 7-1-7 target, including:

1. Surveillance and response stakeholders from the human health, animal and environmental sectors;
2. Preparedness, planning or monitoring and evaluation teams that facilitate International Health Regulations (IHR) assessments and planning;
3. Financing stakeholders, including representatives from ministries of finance (for domestic financing), multilateral development banks and bilateral partners;
4. Government stakeholders responsible for multi-sectoral coordination, policymakers, and parliamentarians;
5. Research and academic stakeholders such as universities and research institutes;
6. Other relevant stakeholders including advocacy groups, civil society and community representatives.

The above stakeholders may play different roles in supporting 7-1-7 implementation as described in the table below. If helpful, countries may choose to use a Stakeholder Mapping Tool to assist in their identification.

After completing the stakeholder mapping, the 7-1-7 champion(s) should guide the identification of a team to lead the coordination of 7-1-7 implementation. Though implementation will require involvement of staff in multiple teams spanning surveillance, investigation and response duties, it is most likely to progress if a single team is clearly assigned responsibility for the early steps, including stakeholder coordination. The 7-1-7 coordination team should expect to work with the champion(s) to conduct initial stakeholder discussions, identify roles and responsibilities, monitor implementation progress and engage in sustained stakeholder outreach and advocacy. Ideally, the implementing team should have responsibility for emergency preparedness and response and possess both adequate staff and the convening power to ensure implementation coordination and tracking of progress.

Once stakeholders who can effectively influence implementation of the 7-1-7 approach have been identified, their consistent and early engagement is required. Informal one-on-one meetings should be held to introduce the approach, address any concerns about implementation, and provide clarity where there may be uncertainty. These meetings can then also lay the groundwork for subsequent stakeholder convenings and implementation planning activities.

Retrospective reviews provide an additional approach to introducing stakeholders to the benefits of 7-1-7 implementation. To conduct a Retrospective Review, the coordination team applies the 7-1-7 approach to recent public health events and presents their findings to stakeholders, thereby directly demonstrating how the approach can be used to assess system performance and identify required remedial actions. The outcomes of these stakeholder engagements may then be used by the champion(s) and coordination team to revise their stakeholder mapping to reflect perceived levels of interest, inform consensus building and define implementation roles.

Before developing a 7-1-7 implementation plan, a landscape analysis should be conducted to identify existing systems for event detection, notification and response, as well as meetings and platforms used to convene surveillance, response and national planning stakeholders. The coordination team should conduct the landscape analysis and then, in conjunction with the stakeholder mapping, use the results to inform the processes and outreach needed for the implementation plan.

Based on the results of the sensitization engagements with stakeholders and landscape analysis, and under the leadership of the champion(s), the coordination team should prepare a 7-1-7 implementation plan jointly with stakeholders. The implementation plan should:

• Describe the implementation approach (real-time or after-an-event) – see
  Step 2.1;
• Clarify stakeholders’ roles and responsibilities;
• Define major activities required for 7-1-7 implementation with appropriate timelines (consider activities around coordination, data collection, performance improvement, national planning, communication and advocacy);
• Propose monitoring and evaluation mechanisms including stakeholder meetings when 7-1-7 performance can be reviewed; and
• Suggest financing mechanisms that may support performance improvement activities.

Once the implementation plan has been drafted, it should be widely circulated to leadership and relevant stakeholders (as identified in Step 1.2) for their review. Depending on the setting, this review can be conducted through a combination of emails, one-on-one stakeholder meetings, existing meetings (e.g., an IHR Technical Working Group), or through a dedicated one-day orientation and validation workshop.

Regardless of the approaches used, validation of the implementation plan should cover the following topics:

• Purpose of the 7-1-7 approach for performance improvement and advocacy;
• Brief description of the 7-1-7 timeliness metrics;
• Illustrative example of how the 7-1-7 approach can be applied to a public health event to elicit performance bottlenecks, enablers and remedial actions;
• Detailed finalization of the implementation plan, including roles and responsibilities of different teams, approaches to collecting 7-1-7 data, timing and venues for convening stakeholders to review 7-1-7 performance.

As a result of the validation processes, stakeholders should obtain a clear understanding of how the 7-1-7 approach informs performance improvement activities, the processes and timelines for 7-1-7 implementation, and their individual roles and responsibilities.

After obtaining buy-in and validation of the implementation plan from stakeholders, implementing jurisdictions may find it helpful to organize an official launch to announce adoption of the 7-1-7 target. This can take the form of a formal in-person event to convene stakeholders for the official commencement of a 7-1-7 project, or a high-level government communication that commits to investment in the 7-1-7 approach. Official commitments can provide a basis for increased transparency in future 7-1-7 performance evaluations and help hold stakeholders accountable to each other and to the broader public. They can help galvanize attention, resources and political will to improve the timeliness of public health threat detection, notification and response.

Jurisdictions implementing the 7-1-7 approach must determine who will collect 7-1-7 performance data. Ideally, 7-1-7 data are captured in real-time for each public health threat by those best positioned to do so, namely public health professionals directly involved in the initial investigation and response. The benefits of the 7-1-7 approach are maximized when it is used in real-time to support an ongoing response; however, the capture of real-time data may not always be possible and it may be necessary to retrospectively collect data after the event response has concluded.

Retrospective data collection can provide value, but can also be time intensive, and locating historical data for all response actions can represent a particular challenge. When retrospective data collection is determined to be necessary, 7-1-7 data may be compiled from the following sources:

• Initial risk assessment;
• Epidemiologic analyses;
• Outbreak situation reports;
• Rapid response team reports;
• Emergency Operation Center meeting notes;
• Event management systems;
• After action review (AAR) reports.

The 7-1-7 Assessment Tool (docx / pdf) captures 7-1-7 data for a single event. While jurisdictions may choose to use this tool, fields from the 7-1-7 Assessment Tool can also be integrated into existing templates for risk assessments, rapid response team reports, or event management systems. This section provides detailed instructions and examples of how to complete the 7-1-7 Assessment Tool. In addition, a document addressing Frequently Asked Questions has been developed.

The date of emergence is often unknown when a health event is first detected. Epidemiologic information gathered during the outbreak investigation should be used to determine the date, based on whatever information is available. The date may then change as more is learned and earlier cases are identified.

The approach to determining the date of emergence varies by type of public health event:

• Endemic diseases: the date when a predetermined increase in case incidence over baseline rates occurred (e.g., IDSR alert thresholds).
• Non-endemic diseases: the date when the index case or first epidemiologically-linked case experienced symptoms.
• Other health threats: the date the threat first met criteria as a reportable event, based on existing reporting standards.

Examples of date of emergence for different event types

The date of detection is the date the public health event was first recorded by any source or in any system. For indicator-based surveillance, the date of detection would be when case or incidence data were recorded (e.g., in a log book, case investigation form, laboratory requisition form). For event-based surveillance (EBS), the date of detection would be when the event information was first recorded (e.g., detected by a media scanning system, recorded by a community health worker, recorded by a hotline operator).

Examples of date of detection, by type surveillance

The date of notification is the date the event is first reported to a public health authority responsible for action. For countries that require notification of reportable events to multiple levels of government that are tasked with different actions, the earliest date that any of these public health authorities were notified would be the date of notification. Oftentimes, the most immediate public health jurisdiction (city, district) will be the public health authority responsible for action and the first public health authority to be notified. In some guidance, this step may be referred to as ‘reporting’ to a public health authority or district health team.

Notification of responsible health authorities could be from a clinical setting to a district surveillance officer. In the case of event-based surveillance or when outbreaks are detected centrally, notification to a responsible authority might be from the central level to the subnational level. This step should not be confused with notification to WHO as defined by the International Health Regulations (2005), which is typically only done after local or national public health authorities have become aware of an event.

Examples of date of notification, by notification scenario

The 7-1-7 approach identifies seven early response actions that should be completed within seven days of notification. The date of early response completion is defined as the latest date on which any of these seven early response actions are completed:

1. Initiate investigation or deploy investigation/response team;
2. Conduct epidemiologic analysis of burden, severity and risk factors, and perform initial risk assessment;
3. Obtain laboratory confirmation of the outbreak etiology;
4. Initiate appropriate case management and infection prevention and control (IPC) measures in health facilities;
5. Initiate appropriate public health countermeasures in affected communities;
6. Initiate appropriate risk communication or community engagement activities;
7. Establish a coordination mechanism.

All seven early response actions may not be applicable for some public health events. For example, an event may be determined to be low risk, such that countermeasures and establishment of a coordination mechanism are not necessary. For events where some response actions are not applicable, the latest date among the applicable actions should be used as the date of early response completion.

In addition to the date of early response completion, it is also recommended to review the date of early response initiation: the date when the first of the seven early response actions was completed. While date of early response initiation is not used to calculate the 7-1-7 metrics, this date is useful to identify bottlenecks to response initiation. It is suggested to aim to initiate the early response within 1 day of notification. The initiation of response actions (i.e., the first action taken) within 1 day can support monitoring of existing guidance for response initiation, as well as monitoring towards WHO’s GPW 13 targets.

The early response actions, defined below, indicate initiation rather than completion of a response, and provide a framework to ensure that the relevant pillars of a response have been activated. They provide simple indicators, modified through pilot testing, to clearly identify a date when actions were taken. Some countries have found that expanding the early response actions into event or disease-specific job aids that outline detailed, specific response actions enhances performance improvement and improves accountability.

*The earliest date should be used for 7-1-7 purposes; these examples are not comprehensive

The value of determining the dates of emergence, detection, notification, and early response completion is to calculate intervals between these events, referred to as timeliness metrics. The calculation of key timeliness metrics allows public health officials and other stakeholders to identify whether the processes for detection, notification, and early response were timely, and whether the event met the 7-1-7 target. These timeliness metrics allow for an assessment of the
performance of the systems for surveillance and early response, and for bottlenecks and enablers to be identified for future planning and action (see Steps 3 and 4).

Calculation of the 7-1-7 timeliness metrics

1. Time to detect = Date of detection – Date of emergence [Target: 7 days]
2. Time to notify = Date of notification – Date of detection [Target: 1 day]
3. Time to complete early response = Date of early response completion – Date of notification [Target: 7 days]

While the 7-1-7 timeliness metrics provide a quantitative measure of the performance of systems for surveillance and early response, on their own they do not provide information about why systems did or did not perform well. Documenting the bottlenecks and enablers of system performance is critical for identifying best practices as well as the specific systems or processes that require strengthening. Bottlenecks and enablers are factors that, respectively, prevent or facilitate timely action.

After recording the timeliness metrics and reviewing whether the 7-1-7 target has been achieved, individuals directly involved in the initial investigation and response should consider holding a participatory session to discuss bottlenecks, enablers and their root causes:

• Review 7-1-7 data to identify bottlenecks and enablers by considering potential reasons that may have hindered or facilitated, respectively, the timeliness of processes in the detection, notification and response intervals. These bottlenecks and enablers may be technical, operational or political.
• When identifying bottlenecks, ensure that they are clear and root causes are determined so these can later be addressed. Examples of clear bottlenecks are provided below. Stakeholders may utilize brainstorming approaches such as “Five Whys,” where “Why?” is simply asked multiple times (more or less than five) in succession until a root cause is determined. Alternative methods that can be used to conduct a root cause analysis are the fishbone diagram, interviews and focus groups.

Review the list of bottlenecks and propose remedial actions that can resolve the bottlenecks. Actions proposed should be made as clear, specific and realistic as possible. Two categories of remedial actions may be surfaced through 7-1-7 implementation:

• Immediate actions: actions for which necessary resources are already available to begin implementation.
• Longer-term actions: actions for which necessary resources are not currently available, but which should be considered in future national planning (e.g., included in National Actions Plans for Health Security, or NAPHS, or funding requests to government or external donors).

Implementation of the immediate actions should begin as soon as possible. For outbreaks that are ongoing, these remedial actions should inform the incident action plan. In most settings, the initial investigation and response team proposing remedial actions may not be empowered to implement them or have the resources to do so. Thus, it is recommended that the proposed actions be presented to a broader group of stakeholders to obtain the necessary buy-in and financial resources. This process is described in Step 3.

After each public health event, data originally captured on the 7-1-7 Assessment Tool should be stored in a single location in order to facilitate performance analysis across events. Ideally, these data should be captured in event or project management systems used to track other activities and collect other surveillance and/or response data. Jurisdictions lacking a suitable existing data system may choose to use the Data Consolidation Spreadsheet, a Microsoft Excel database developed to support implementation of the 7-1-7 approach. This tool contains four different sheets:

1. Input timeliness data: This page of the worksheet permits jurisdictions to record timeliness metrics, bottlenecks and enablers for each public health event reviewed against the 7-1-7 target;
2. Assess 7-1-7 results: This page automatically calculates the three timeliness metrics for each public health event and generates tables and graphs that summarize performance across all events entered in the spreadsheet;
3. Track remedial actions: This page allows jurisdictions to record all remedial actions identified as well as the responsible authority and implementation status;
4. Bottleneck analysis: This optional page can be used by jurisdictions to consolidate the bottlenecks identified through 7-1-7 implementation and categorize them, facilitating identification of the most common bottleneck types. This analysis has been found useful in helping jurisdictions prioritize longer-term remedial actions for funding.

An essential component of 7-1-7 implementation is deciding on an approach for convening key stakeholders to review performance against the 7-1-7 metric and discuss remedial actions for future improvement. While a real-time review of events is ideal to enable immediate improvements, different approaches can be used to convene stakeholders, as described below:

Once stakeholders have been convened, 7-1-7 performance should be reviewed for individual public health events. This review should contain the following key components:

• Brief narrative description of the public health threat;
• Timeline of key milestones (including the four 7-1-7 timeliness milestones) and calculation of the three timeliness metrics;
• Descriptions of bottlenecks and enablers to detection, notification, and early response;
• Proposed remedial actions to address bottlenecks and improve preparedness for future threats.

The 7-1-7 event review slide template can be used to present 7-1-7 data from a single public health event to stakeholders. This template was designed to facilitate a 10-minute presentation that raises stakeholder awareness of performance bottlenecks and facilitates a discussion of appropriate remedial actions and improvement of ongoing and future responses.

The output of the stakeholder review of 7-1-7 performance is a consensus list of remedial actions. Actions agreed to be immediate should be designated to a responsible authority provided with the necessary resources to complete them. Longer-term actions should be documented for consideration during future planning activities. All actions should be recorded in a database. Ideally actions from 7-1-7 may be captured in existing project management software or databases or on the action tracker sheet of the Data Consolidation Spreadsheet. All actions should be written using the SMART criteria (specific, measurable, attainable, relevant, and time-bound) described in detail in Step 2.2.7.

When conducting routine response or review meetings on 7-1-7 implementation, an agenda item reviewing the implementation status of immediate remedial action items identified at prior meetings should be included. This will increase accountability and help ensure that actions are completed in a timely manner and lead to performance improvement. Some actions initially selected for immediate implementation may remain incomplete and ultimately need to be considered alongside other longer-term actions in future planning activities.

Prior to analyzing consolidated 7-1-7 data, the following actions should be completed:

1. Confirm that all data have been entered: Review the list of public health events that occurred during the period of interest and confirm that all event data have been entered in the appropriate databases.
2. Clean the data: Review the data entered in the databases and check for any missing fields. In addition, check the calculated values for each of the three timeliness metrics and confirm that any outliers (e.g., negative numbers, large numbers) are correct. For jurisdictions using the Data Consolidation Spreadsheet, this can be done by reviewing outputs on the “Assess 7-1-7 Results” sheet where the timeliness metrics are automatically calculated, and blanks and negative values highlighted.

7-1-7 data across public health events should be routinely synthesized in a brief report for dissemination to stakeholders and policy makers. Objectives of this Synthesis Report include:

• Providing a high-level summary of the most important learnings from 7-1-7 implementation. These can be prioritized based on observed frequency of bottlenecks or anticipated system-wide impacts of interventions;
• Informing stakeholders of performance against the 7-1-7 target;
• Reviewing progress in completing immediate actions selected to improve epidemic preparedness;
• Consolidating and disseminating long-term actions in order to inform planning and financing requests, including integration into NAPHS or similar plans and alignment with funder priorities.

The ideal frequency of Synthesis Report dissemination will vary based on the number of public health events within a jurisdiction, available human resources, and the periodicity of planning activities and funding opportunities that can support completion of remedial actions. At a minimum, a report should be developed and disseminated shortly before each planning cycle. The sub-steps below describe key components of a Synthesis Report.

Calculating the proportion of events that meet each component of the 7-1-7 target provides stakeholders with a high-level understanding of a jurisdiction’s performance. It can help understanding of whether systems used for detection, notification, or early response are able to routinely complete timely and appropriate actions. It is recommended that countries present the proportion of events meeting each component of the 7-1-7 target, rather than presenting medians. Median results may be misinterpreted by stakeholders as success when they in fact indicate that only half the events have met the target and critical system strengthening needs may still exist.

Jurisdictions should perform the following calculations:

• The proportion of events that meet each of the three components of the 7-1-7 target;
• The proportion of events that met all three components of the 7-1-7 target;
• For each of the seven early response actions, the proportion of events where the early response action was completed within 7 days.

Jurisdictions that have implemented the 7-1-7 approach over multiple reporting periods should evaluate if the proportion of events meeting the 7-1-7 target is increasing over time. This can demonstrate progress (or lack thereof) to stakeholders.

As a result of implementation of the 7-1-7 approach, a list of bottlenecks and proposed remedial actions will be compiled. To facilitate prioritization, jurisdictions have found it useful to categorize bottlenecks, the most common categories suggesting the areas most likely in greatest need of remedial actions and investment.

A list of bottleneck categories has been developed to support this process. In addition, the Data Consolidation Spreadsheet contains a sheet to list bottlenecks and assign them to a category. A table is then automatically generated showing the frequency of each category of bottleneck.

Depending on a jurisdiction’s context and the number of events reviewed using the 7-1-7 approach during the reporting period, the following additional analyses may be considered for inclusion in a Synthesis Report:

• 7-1-7 performance by event type;
• 7-1-7 performance by geographic area (e.g., region or district);
• Review of the most common bottlenecks for detection, notification, and response;
• Review of bottlenecks by the level(s) of the health system where they occur (e.g., community, health facility, intermediate, or national level).

The 7-1-7 approach identifies bottlenecks and remedial actions that can feed into the development of operational (annual) or strategic (multi-year) planning cycles, including National Action Plans for Health Security (NAPHS). In many settings, effective NAPHS implementation has been hindered by lack of prioritization. Integrating the 7-1-7 approach into the NAPHS process, and focusing on areas identified for performance improvement, helps define a more feasible number of priorities per IHR technical area for financing and implementation.

To facilitate this process:

• Ensure that critical stakeholders are involved in event reviews, so that they understand the 7-1-7 approach and rationale for the identification of bottlenecks and corresponding remedial actions;
• Ensure that remedial actions are assigned to relevant IHR technical areas since, commonly, technical area priorities are defined before consolidation into national plans;
• The 7-1-7 approach must be considered alongside the results of IHR and other assessments, including WHO benchmark recommendations to determine NAPHS priorities. In determining what to prioritize during an implementation period, 7-1-7 bottlenecks and remedial actions can be incorporated as additional items or included as a result of reprioritization of relevant actions from the previous cycle.

The Synthesis Report is designed to include information needed by stakeholders to support these steps and must be disseminated to stakeholders before national planning meetings.

The results of 7-1-7 assessments or the Synthesis Report can help surface investment priorities from the planning and prioritization exercises conducted in Step 4, and identify whether they lend themselves to being addressed through advocacy.

A landscape analysis can then prove useful to assess the country-specific context, understand the needed changes to be pursued (policy, budget or program), support the translation of investment priorities into specific objectives (e.g., increased domestic funding for national priorities identified by 7-1-7 for the next budget cycle), and serve as a basis for the development of a targeted advocacy strategy.

Assessment of the political landscape and budget process can allow for the development of more targeted approaches to ensure that plans developed in Step 4 are integrated into the budget planning process. The necessary tools for conducting a landscape analysis, including budget cycle mapping, political landscape, and stakeholder mapping, are provided in the Budget Advocacy Toolkit.

The 7-1-7 target can focus the world’s attention on the need for effective and swift outbreak response and become a rallying point for a virtuous cycle of advocacy and accountability. After the landscape analysis has been completed and policy objectives and strategies set, the 7-1-7 approach can be used as a tool for effective communication of the systems and actions required to strengthen health security.

Communications with stakeholders can be undertaken in different ways, using different tactics and assets, alone or in combination, with adjustments over time. They should be informed by the targeted advocacy strategy developed in Step 5.1. Stakeholders will inherently have different interests and areas of influence.

Different types of stakeholder roles may include:

Government stakeholders:

Government stakeholders have influence over what is included in national budgets and on implementation priorities. The 7-1-7 target allows governments to identify points of failure and bottlenecks across outbreak responses. Because the 7-1-7 approach highlights the interplay of various systems, it helps focus accountability rather than just vaguely attributing failed responses. It provides data to help drive decision-making — where to direct attention, training, technical assistance, and funding. Ministries of Health, National Public Health Institutes (NPHI) and local and other officials can reference transparent reporting to advocate for increased investment of domestic resources in systems to improve performance against the 7-1-7 target. They can also use the 7-1-7 approach to increase and focus support from external donors, while building confidence that funds will be targeted to critical needs and impacts will be measured.

Civil society and communities:

Civil society and communities have been amongst the most potent forces in advocating for resources and programs to address the HIV pandemic and in demanding accountability from officials when shortcomings are identified. Over the past decades, they have used HIV treatment targets to mobilize action. Civil society and community organizations can have a significant impact in terms of mobilizing funds for outbreak preparedness and response, while tracking how funds are spent and demanding accountability. The 7-1-7 approach can further support efforts by advocates to push for increased attention and funding where gaps exist and governments fail to invest adequately in epidemic preparedness.

Funders and development partners:

Part of the reluctance to fund epidemic preparedness stems from the absence of simple measurements of progress as well as a lack of prioritized funding needs. As in the case of HIV, synthesized data collected against the 7-1-7 metrics can help funders and development partners (including foundations, bilateral donors, development banks and technical assistance providers) understand how best to direct resources and structure program funding, while also offering a measure of funding impact. With measurable metrics and an evidence-based list of priority needs — a requirement for bringing major funding on board — the 7-1-7 approach helps focus funding contributions on areas of greatest need and builds confidence that funds are well spent.

Depending on the specific demands and opportunities for engagement, different assets and tactics can be employed to leverage the 7-1-7 target as a communications and advocacy tool. These include:

• Workshops or high-level conferences to obtain consensus and buy-in;
• Individual meetings to identify opportunities and obtain commitments;
• Presentations to key committees or interest groups;
• Policy briefs;
• Media campaigns;
• Editorials or publications;
• Planning documents.

Routine collation and synthesis of 7-1-7 data (Step 4) can help demonstrate progress and highlight persistent bottlenecks. Routine reports (quarterly, annual) can also provide evidence of performance improvement to stakeholders (government, civil society, and funders) and detailed feedback on the value of their investments.

If performance against the 7-1-7 metrics is not progressing as expected, the data can be used to communicate where additional investments are needed. Data collected through the 7-1-7 approach should also be used to identify enablers and those aspects of the system that are working. Demonstrating the success of public health efforts in preventing epidemics and other health threats is a challenge, because the mark of success is when nothing happens. The 7-1-7 approach not only makes the successful containment of public health threats more concrete, but also identifies the specific system factors and investments responsible for success.