Evaluating Zambia's Implementation of IHR Core Capacities: Insights from the 2017 and 2023 Joint External Evaluations

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This study compares Zambia’s 2017 and 2023 JEE results to assess progress in IHR core capacities. We extracted scores from official JEE reports and undertook descriptive comparisons by category (Prevent, Detect, Respond, and Other IHR-related hazards and Points of Entry), complemented by a brief thematic review of recommendations. Differences in JEE tool editions were addressed through systematic indicator mapping to ensure comparability. Between 2017 and 2023, Zambia recorded the largest gains in the Respond category (mean 1.62 to 2.25; +0.63 points, + 38.5%). Marked improvements were observed in IHR coordination (1.00 to 2.70; +170.0%), surveillance (2.40 to 3.70; +54.2%), and points of entry (1.00 to 3.70; +270.0%). Detect improved modestly (2.70 to 2.90; +7.4%), while Prevent was essentially unchanged (2.39 to 2.37; −0.8%). Notable declines were seen in antimicrobial resistance (3.50 to 2.40; −31.4%), immunisation (4.00 to 2.70; −32.5%), and chemical events (2.50 to 1.00; −60.0%). Qualitative findings suggest strengthened coordination via the Zambia National Public Health Institute (ZNPHI), but persistent gaps in antimicrobial resistance and chemical-event preparedness. Overall, Zambia has advanced emergency response and surveillance capacities, likely reflecting ZNPHI establishment and COVID-19 investments, yet weaknesses remain in antimicrobial resistance, routine immunisation, and chemical hazard management. Priorities include restoring immunisation coverage, expanding One Health antimicrobial resistance surveillance, and improving chemical event readiness. These insights can guide updates to the National Action Plan for Health Security and resource allocation in resource-constrained settings. International Health Regulations Joint External Evaluation health security Zambia surveillance antimicrobial resistance emergency preparedness public health capacity Figures Figure 1 Introduction The frequency and impact of public health emergencies have increased markedly in recent decades, as evidenced by global outbreaks such as SARS, H1N1, Ebola, COVID-19 and most recently Mpox. These events have exposed significant weaknesses in global health security systems and underscored the need for coordinated international frameworks to manage disease threats across borders [ 1 , 2 ]. In response, the International Health Regulations (IHR, 2005) were adopted by 196 countries as a legally binding instrument to strengthen core public health capacities for the prevention, detection, and response to events of international concern [ 2 ]. In the WHO African Region, the risk of epidemics remains high due to factors such as rapid population growth, unplanned urbanisation, climate change, cross-border mobility, and limited health system capacity [ 3 , 4 ]. The region reports over 150 acute public health events annually, with cholera, measles, and viral haemorrhagic fevers among the most frequent [ 5 ]. To operationalise the IHR, the region adopted the Integrated Disease Surveillance and Response (IDSR) strategy in the late 1990s and introduced the Joint External Evaluation (JEE) as part of the IHR Monitoring and Evaluation Framework. By 2019, 40 of 47 Member States had completed JEEs, revealing critical capacity gaps in areas such as antimicrobial resistance (AMR), biosafety, emergency operations, and chemical and radiation event preparedness [ 3 ]. The JEE is a voluntary, multisectoral assessment designed to evaluate country-level IHR capacities across 19 technical areas. The tool has evolved over time, with the latest edition (JEE 3.0) incorporating lessons from the COVID-19 pandemic to improve assessment accuracy [ 6 ]. The pandemic further highlighted global weaknesses in IHR implementation, particularly in managing risks linked to urbanisation, AMR, climate change, and human–animal interaction [ 7 ]. As such, scholars have called for a reconceptualization of health security through a human security lens that emphasises equity, multisectoral action, and population-centred approaches [ 8 ]. Zambia, like many countries in the region, remains vulnerable to both endemic and emerging health threats. In recent years, the country has experienced concurrent outbreaks of cholera, measles, anthrax, and COVID-19, with rural areas disproportionately affected due to inadequate infrastructure, particularly unreliable electricity in over 60% of health facilities [ 9 , 10 ]. To evaluate its readiness under the IHR, Zambia conducted its first JEE in 2017, which identified major gaps in risk communication, laboratory systems, and medical countermeasures [ 11 , 12 ]. In response, the Zambia National Public Health Institute (ZNPHI) was established in 2018 to enhance coordination and strengthen surveillance and response capacity. A second JEE, conducted in 2023, assessed progress made since 2017 and informed the development of Zambia’s National Action Plan for Health Security. Preliminary results indicate notable improvements in surveillance, emergency management, and points of entry, largely attributed to COVID-19-related investments and strengthened multisectoral coordination through ZNPHI [ 13 ]. Nonetheless, challenges remain in addressing AMR, immunisation coverage, and preparedness for chemical events. This study provides a comparative analysis of Zambia’s 2017 and 2023 JEE results, with the following objectives: (1) assess progress across the 19 IHR technical areas; (2) identify major improvements and persistent gaps; (3) examine contextual and institutional factors influencing performance; and (4) offer policy-relevant recommendations to strengthen Zambia’s health security architecture. This study adopts a health system resilience perspective, recognising that the ability to maintain and adapt core public health functions in the face of emergencies is central to IHR implementation. By analysing Zambia’s JEE results over time, we assess not only capacity levels but also the system’s adaptive performance across critical domains. Methodology This study conducts a comparative analysis of Zambia’s 2017 and 2023 JEE scores to assess progress in implementing IHR core capacities. The JEE, developed by the World Health Organization (WHO), evaluates a country’s ability to prevent, detect, and respond to public health threats across 19 technical areas, categorized into Prevent, Detect, Respond, and Other IHR-Related Hazards and Points of Entry [6]. The 2017 JEE utilized the second edition of the JEE tool, while the 2023 JEE employed the third edition (JEE 3.0), which incorporated lessons from the COVID-19 pandemic, introducing new indicators such as gender equity and expanded antimicrobial resistance (AMR) metrics. Data Sources Primary data were sourced from the official 2017 and 2023 JEE reports for Zambia, accessed via the WHO JEE repository [12, 13]. These reports provide detailed assessments, including scores (1 = no capacity, 5 = sustainable capacity), recommendations, and contextual narratives from stakeholder consultations, site visits, and document reviews conducted during the JEE process. Supplementary data were obtained from national health policies (e.g., National Health Strategic Plan 2022–2026 [14] and WHO country cooperation strategy [15]) to contextualize findings and explore influencing factors such as policy reforms and funding. Handling Changes in JEE Format The transition from the second to the third edition of the JEE tool introduced changes in technical areas and indicators, increasing from 49 to 56 indicators while maintaining 19 technical areas [6]. To ensure comparability, several steps were implemented. First, indicators that remained unchanged between the two editions, such as laboratory testing capacity, were directly compared to assess progress. Second, new JEE 3.0 indicators, such as gender equity in health emergency management, were mapped to related 2017 indicators like workforce development to ensure continuity. Finally, modifications in technical areas were categorized into splits, mergers, or removals. For example, 'National legislation, policy, and financing' in the 2017 JEE was split into two separate technical areas in 2023: 'Legal instruments' (covering legislation and policy) and 'Financing' (covering funding mechanisms). To enable comparison, the 2023 scores for these two areas were combined using a weighted average: the mean of the two 2023 scores was calculated and compared against the single 2017 score. Conversely, when technical areas were merged, such as 'Emergency preparedness' and 'Emergency operations centre' becoming 'Health emergency management' in 2023, the 2017 scores from both legacy areas were averaged to create a comparable baseline. This approach maintains the relative weight of each component while enabling valid trend analysis. Similarly, the dropped area 'Reporting' was redistributed across related technical areas such as 'IHR coordination' based on indicator content mapping documented in WHO's JEE 3.0 transition guidance. Data Extraction and Verification Data extraction involved a systematic review of JEE reports using a standardized Excel template to record scores, recommendations, and contextual notes for each technical area. Two researchers independently extracted data to ensure reliability, achieving an inter-rater reliability of 95%. Discrepancies were resolved through consensus discussions, guided by a third researcher when necessary. Verification was conducted by cross-referencing JEE data with national health plans, situation reports, and donor documents to confirm accuracy and consistency. Analytical Framework The analysis was structured around four components. First, a descriptive quantitative comparison was conducted in which JEE scores for 19 technical areas, grouped into Prevent, Detect, Respond, and Other IHR-Related Hazards and Points of Entry, were compared between 2017 and 2023 using Microsoft Excel and R (version 4.3.2). Absolute differences and percentage changes were calculated to illustrate directional progress, and descriptive statistics summarised changes at category and technical-area level. Second, a thematic review of the 2017 JEE recommendations was undertaken to identify implementation progress by 2023, focusing on recurrent themes in coordination, workforce development, and resource constraints. Third, a contextual analysis examined factors that may have influenced observed changes, including policy reforms (such as the establishment of the Zambia National Public Health Institute in 2018), external funding streams, and major public health events (for example, COVID-19 and the 2023 anthrax outbreak). Finally, a benchmarking exercise compared Zambia’s 2023 scores with WHO African Region and global reference values using published JEE summaries and regional analyses to situate Zambia’s performance relative to other countries in the Region. Ethical Considerations The study utilized publicly available JEE reports and adhered to WHO ethical guidelines for data handling. No primary data collection involving human subjects was conducted, negating the need for ethical approval. Results Overall JEE Score Comparison Zambia’s JEE scores showed varied changes between 2017 and 2023 (Table 1). The Respond category recorded the largest improvement, with the average score increasing from 1.62 to 2.25 (+0.63; +38.5 %), reflecting substantial gains in emergency management and intersectoral coordination. The Detect category also improved slightly, rising from 2.70 to 2.90 (+0.20; +7.4 %), largely driven by strengthened surveillance systems. The Other IHR-Related Hazards and Points of Entry category increased from 1.83 to 2.07 (+0.24; +12.7 %), mainly due to enhanced capacity at points of entry. The Prevent category remained relatively stable, declining marginally from 2.39 to 2.37 (–0.01; –0.6 %). Figure 1 presents a comparison of JEE scores across all 19 technical areas between 2017 and 2023, organized by category. While the magnitude of improvement varied across categories, the overall pattern indicates directional progress—particularly in response and detection capacities, reflecting Zambia’s strengthened coordination and surveillance under the Zambia National Public Health Institute (ZNPHI). Table 1 : Average JEE Scores by Category (2017 vs. 2023) Category 2017 score 2023 score Difference % Change Interpretation Prevent 2.39 2.37 -0.01 -0.6 % Stable – no meaningful change Detect 2.70 2.90 +0.20 +7.4 % Small improvement in detection capacity Respond 1.62 2.25 +0.63 +38.5 % Moderate improvement, notably in emergency management and coordination Other IHR-Related Hazards and Points of Entry 1.83 2.07 +0.24 +12.7 % Slight improvement, driven by stronger border-health measures Note: Changes are presented descriptively to illustrate directional progress. Source: Authors’ analysis based on WHO JEE reports (2017 and 2023). Technical Area Changes Scores for individual technical areas within each category are presented in Table 2 and visualized in Figure 1. Prevent: The average score decreased from 2.39 to 2.37. Increases occurred in IHR coordination, communication, and advocacy (1.00 to 2.70, +1.7, 170.0%), national legislation, policy, and financing (2.00 to 2.50, +0.5, 25.0%), and biosafety and biosecurity (1.50 to 2.00, +0.5, 33.3%). Declines were observed in antimicrobial resistance (3.50 to 2.40, -1.1, -31.4%), immunization (4.00 to 2.70, -1.3, -32.5%), and zoonotic diseases (2.70 to 2.30, -0.4, -14.8%). Food safety remained unchanged (2.00). Detect: The average score increased from 2.70 to 2.90. Surveillance improved (2.40 to 3.70, +1.3, 54.2%), while workforce development declined (2.70 to 2.00, -0.7, -25.9%). The national laboratory system remained stable (3.00). Respond: The average score increased from 1.62 to 2.25. Improvements occurred in health emergency management (1.30 to 2.30, +1.0, 76.9%), linking public health and security authorities (1.00 to 2.00, +1.0, 100.0%), and health service provision and IPC (1.00 to 2.00, +1.0, 100.0%). Risk communication declined (3.20 to 2.70, -0.5, -15.6%). Other IHR-Related Hazards and Points of Entry : The average score increased from 1.83 to 2.07. Points of entry improved (1.00 to 3.70, +2.7, 270.0%), while chemical events (2.50 to 1.00, -1.5, -60.0%) and radiation emergencies (2.00 to 1.50, -0.5, -25.0%) declined. Table 2 : JEE Scores by Category and Technical Area (2017 vs. 2023) Category Technical Area 2017 Ave Score 2023 Ave Score Prevent Prevent Average 2.39 2.37 National legislation, policy and financing 2.00 2.50 IHR coordination, communication and advocacy 1.00 2.70 Antimicrobial resistance 3.50 2.40 Zoonotic diseases 2.70 2.30 Food safety 2.00 2.00 Biosafety and biosecurity 1.50 2.00 Immunization 4.00 2.70 Detect Detect Average 2.70 2.90 National laboratory system 3.00 3.00 Surveillance 2.40 3.70 Human Resources and Workforce development 2.70 2.00 Respond Respond Average 1.62 2.25 Health emergency management 1.30 2.30 Linking public health and security authorities 1.00 2.00 Health Service Provision and IPC 1.00 2.00 Risk communication 3.20 2.70 Other IHR Hazards and Points of Entry Other Average 1.83 2.07 Points of entry 1.00 3.70 Chemical events 2.50 1.00 Radiation emergencies 2.00 1.50 Note : Scores range from 1 to 5, with higher scores indicating greater capacity. Category averages are the mean of technical area scores within each category, rounded to two decimal places. Category averages are presented descriptively; no formal significance testing was conducted. A line graph, faceted by category, shows score changes for each technical area, highlighting increases in IHR coordination, surveillance, and points of entry, and declines in AMR, immunization, and chemical events (figure 1). Qualitative Thematic Analysis To complement the quantitative results, qualitative thematic analysis was undertaken to contextualise observed trends. Thematic review of recommendations from the 2017 JEE identified three recurrent themes reflecting Zambia’s progress by 2023. First, establishment of the Zambia National Public Health Institute (ZNPHI) markedly improved intersectoral coordination and emergency response, aligning with gains in the Respond category. Second, partial implementation of laboratory system and workforce reforms enhanced surveillance capacity but left persistent shortages in trained personnel, echoing the moderate improvement observed under Detect . Third, limited domestic financing and weak multisectoral collaboration constrained full implementation of antimicrobial-resistance, immunisation, and chemical-event preparedness activities, areas showing score declines. Overall, the qualitative findings corroborate the quantitative results, highlighting both institutional progress and remaining structural bottlenecks in health-security capacity building. Discussion The comparison of Zambia’s 2017 and 2023 JEE scores, as shown in Table 1 and Fig. 1 , highlights both progress and persistent gaps in IHR core capacities. The analysis addressed the objectives of examining changes across technical areas, identifying improvements and setbacks, and interpreting these changes in the context of Zambia’s health security architecture, which operates in a region where infectious diseases remain a major cause of mortality. Three overarching patterns emerge from the results. First, response capacities improved markedly (+ 38.5%), reflecting strengthened emergency coordination and management systems. Second, detection capacities showed modest but meaningful gains (+ 7.4%), particularly in surveillance. Third, prevention capacities remained largely stagnant or declined in critical areas, notably antimicrobial resistance (-31.4%) and immunization (-32.5%). These divergent trajectories suggest uneven progress across the IHR framework, warranting closer examination of category-specific drivers and constraints. The notable improvement in the Respond category is consistent with strengthened emergency management and multisectoral coordination led by the Zambia National Public Health Institute (ZNPHI), established in 2018. ZNPHI has coordinated responses to cholera, measles, anthrax, and mpox, contributing to faster detection, escalation, and management of public health events [ 16 ]. These gains suggest that Zambia is now better able to manage acute infectious threats. However, gaps in multi-hazard preparedness remain, particularly for chemical events and other non-communicable hazards such as radiation emergencies, which are increasingly relevant in the context of industrial growth and climate-related risks. The increase observed in the Detect category, particularly in surveillance, reflects the continued implementation of the IDSR system and the consolidation of laboratory and event reporting functions under ZNPHI [ 17 ]. Stronger surveillance capacity is critical in a subregional context characterised by highly mobile populations and cross-border disease transmission in Southern Africa. The marked improvement at points of entry is consistent with COVID-19-era investment in border screening infrastructure and protocols, which has been prioritised across the WHO African Region to limit cross-border spread. By contrast, declines in antimicrobial resistance (AMR), immunisation, and chemical event preparedness indicate structural weaknesses. Setbacks in AMR likely reflect limited surveillance coverage, weak laboratory stewardship systems, and incomplete One Health coordination between human, animal, and environmental health sectors [ 7 ]. The decline in immunisation capacity is consistent with documented COVID-19-era disruptions to routine vaccination and follow-up services in Zambia and the region [ 18 , 19 ]. Reduced capacity for chemical event management likely reflects underinvestment in specialised technical preparedness during a period in which national and partner funding was channelled primarily to infectious disease response [ 20 , 21 , 22 ]. These declines warrant particular attention, as they occurred despite overall system strengthening in other domains and illustrate critical trade-offs in health emergency management: surge capacity for acute threats can inadvertently weaken foundational prevention programmes when systems lack sufficient redundancy or ring-fenced resources [ 23 ]. Similarly, the focus on infectious disease surveillance and response diverted attention and technical resources away from chemical and radiation emergency preparedness, which require specialized equipment, training, and protocols distinct from those used for biological threats [ 24 ]. These trade-offs highlight the tension between vertical (disease-specific) and horizontal (systems-wide) approaches to health security [ 25 ], and underscore the need for integrated planning that protects core prevention functions even during emergency response periods [ 26 ]. Benchmarking Zambia's 2023 scores against regional and global patterns shows mixed performance. Zambia's Detect capacity (2.90), driven by surveillance (3.70), exceeds the WHO African Region average and reflects pandemic-era investments in disease detection systems that have strengthened capacity across the continent. This continues a historical pattern in which detection has generally outpaced prevention in the region [ 3 ], a trend that persists in the post-COVID-19 era. However, Zambia's Prevent capacity (2.37) and preparedness for chemical events remain weak, echoing a continental challenge in which prevention and non-infectious hazard management continue to lag behind outbreak response capabilities. Compared with global trends, Zambia's profile still falls below the proportion of countries reporting more mature prevention and response capacity, indicating the need to build sustained readiness beyond infectious disease control [ 27 ]. This pattern of stronger infectious disease response relative to other hazards reflects both funding architecture and risk perception: international financing mechanisms and technical assistance have historically prioritized epidemic-prone diseases, while domestic capacity for chemical and radiation events remains chronically under-resourced [ 20 ]. The result is an asymmetric preparedness profile that, while appropriate to Zambia's epidemiological context, may leave the country vulnerable to industrial accidents, environmental contamination, and other non-infectious hazards as urbanization and mining activities expand. The qualitative thematic analysis supports these interpretations. First, the establishment and mandate of ZNPHI improved coordination and emergency management, explaining the gains in Respond and in surveillance under Detect. Second, partial implementation of laboratory and workforce reforms contributed to surveillance improvements but did not fully address workforce shortages, which remain critical for sustained capacity, particularly outside urban centres. Third, limited domestic financing and fragmented multisectoral engagement constrained progress in antimicrobial resistance, immunisation, and chemical event preparedness. These thematic findings show that Zambia’s progress has been institutionally driven, but also remains vulnerable to funding structure, workforce availability, and scope of mandate. Implementation considerations are already visible in Zambia’s National Action Plan for Health Security (NAPHS). The WHO IHR Benchmarking Tool aims to move technical areas at levels 1–2 toward at least level 3 (“developed capacity”), with a focus on realistic, sequenced actions [ 28 ]. Zambia has aligned its NAPHS with this approach, supported by catalytic financing from mechanisms such as the Pandemic Fund and the Global Fund, which have funded emergency operations, workforce development, biosafety, and simulation exercises [ 29 ]. Although Zambia’s aggregate scores remain below global averages in prevention and multi-hazard response, this targeted investment pathway indicates a structured route for progressive capacity strengthening [ 15 ]. This analysis has limitations. First, score comparisons are descriptive and reflect directional change rather than statistically tested differences; this approach is consistent with the ordinal nature of JEE scoring. Second, differences in tool editions between 2017 and 2023 required indicator mapping, which may introduce some classification uncertainty despite systematic alignment. Third, reliance on national JEE reports risks underrepresenting subnational and community-level capacities. Fourth, JEE assessments involve a degree of self-reporting by host countries, which may introduce social desirability bias or optimistic scoring, particularly in areas where demonstrable evidence is limited. The external evaluation process and multisectoral validation mechanisms partially mitigate this risk, but the potential for overestimation of capacity or conversely, underreporting where systems lack documentation, should be acknowledged. These limitations were mitigated through triangulation with national policy documents and WHO strategic reports. Future work should assess how national-level capacity translates into subnational readiness, especially in provinces and districts with recurrent outbreaks and limited infrastructure. Further assessment of non-infectious hazards — including chemical and radiation events — is also critical, given their low-capacity scores but high potential impact on both workers and surrounding communities. Recommendations To strengthen Zambia’s IHR core capacities, the following prioritized, actionable recommendations are proposed, aligned with the National Health Strategic Plan 2022–2026: High-priority actions: Restore immunisation capacity (Prevent – Immunisation): Implement targeted community outreach and catch-up vaccination programmes, with a focus on high-risk and hard-to-reach populations, to reverse declines in routine immunisation performance. Strengthen antimicrobial resistance (Prevent – Antimicrobial Resistance): Develop and operationalise a national One Health antimicrobial resistance surveillance and stewardship framework, in collaboration with Africa CDC, to improve real-time detection and coordinated response across human, animal, and environmental sectors. Improve readiness for chemical events (Other – Chemical Events): Invest in specialised training, equipment, and standard operating procedures for chemical incident detection and response, working with technical partners (e.g. UKHSA, USAID) to build dedicated national and subnational response capacity. Medium-priority actions: Expand and retain the health security workforce (Detect – Workforce Development): Scale targeted workforce development and retention strategies, especially outside Lusaka and Copperbelt, to address persistent shortages in trained epidemiologists, laboratory personnel, and rapid response staff. Reinforce risk communication (Respond – Risk Communication): Strengthen public risk communication and community engagement systems, including digital and local-language channels, to maintain public trust during outbreaks and other emergencies. Integrate zoonotic disease surveillance (Prevent – Zoonotic Diseases): Formalise data-sharing and joint investigation mechanisms between veterinary and public health authorities, building on the recent multisectoral response to anthrax. Long-term systems measures Institutionalise IHR financing and accountability (Governance / IHR Coordination): Update public health legislation and financing arrangements to embed IHR core capacity funding lines in domestic budgets, reducing dependence on external partners. Create a national IHR / health security task force (IHR Coordination): Establish a permanent, ZNPHI-led multisectoral mechanism to monitor implementation of the National Action Plan for Health Security (NAPHS) and maintain coordination gains beyond emergency periods. Address non-infectious hazard preparedness (Other – Chemical Events, Radiation Emergencies): Develop and test multi-hazard preparedness plans for chemical and radiation events, aligned with the Sendai Framework, with simulation exercises and after-action reviews integrated into routine preparedness cycles. Conclusion Zambia’s comparison of JEE results from 2017 to 2023 shows measurable gains in response capacity, surveillance, and points of entry, alongside ongoing weaknesses in antimicrobial resistance, immunisation, multi-hazard preparedness, and workforce depth. These patterns reflect targeted improvements in coordination and emergency management, particularly following the establishment of the Zambia National Public Health Institute, but also reveal areas in which progress has not kept pace, especially for chemical events and other non-infectious hazards. The findings directly inform Zambia’s National Action Plan for Health Security and illustrate how countries can translate JEE results into sequenced capacity-building investments under the International Health Regulations. They also underscore that sustaining progress will require not only external financing and emergency surge capacity, but also long-term domestic investment in workforce, governance, and preparedness systems. Strengthening these foundations is essential if Zambia is to manage both recurrent infectious outbreaks and emerging non-infectious threats, and to contribute reliably to regional and global health security in a way that is equitable and people centred. Declarations Conflict of Interest The authors declare no competing interests. Funding This study received no specific funding. The authors were supported by their respective institutions. Acknowledgments We thank the Zambia National Public Health Institute (ZNPHI) and the Ministry of Health Zambia for providing access to JEE reports and related data. We acknowledge the World Health Organization (WHO) for facilitating JEE assessments in the African Region. Data Availability The data used in this study, including Zambia’s 2017 and 2023 JEE reports, are publicly available through the WHO JEE repository. Author Contributions Moses Mwale: Conceptualisation, Methodology, Formal analysis, Data curation, Visualisation, Writing – original draft, Writing – review and editing. Gabriel Yali: Conceptualisation, Methodology, Data acquisition, Validation, Writing – review and editing. Peter Jay Chipimo: Supervision, Validation, Writing – review and editing. Precious Kalubula: Validation, Writing – review and editing. Kelvin Mwangilwa: Validation, Writing – review and editing. Nyuma Mbewe: Investigation, Writing – review and editing. Paul Zulu: Data acquisition, Project administration, Writing – review and editing. Davie Simwaba: Validation, Writing – review and editing. Freddie Masaninga: Resources, Writing – review and editing. O-tipo Shikanga: Supervision, Writing – review and editing. Nyambe Siyange: Validation, Writing – review and editing. Peter Clement Lasuba: Supervision, Resources, Project administration, Writing – review and editing. Ethics Approval and Consent to Participate This study did not require ethical approval, as it involved the analysis of data obtained from publicly available JEE reports and did not involve human participants, identifiable personal data, or biological samples. No primary data were collected. Therefore, consent to participate was not applicable. Consent to Publish No individual identifying information is included in this manuscript. Consent to publish was therefore not required. References S. Moon, D. Sridhar, M. Pate, A. Jha, C. Clinton, S. Delaunay, V. Edwin, M. Fallah, D. Fidler, L. Garrett, E. Goosby, L. Gostin, D. Heymann, K. Lee, G. Leung, J. Morrison, J. Saavedra, M. Tanner, J. Leigh and B. Hawkins, “Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola.,” The Lancet, vol. 386, no. 10009, p. 2204–2221, 2015. WHO, “International Health Regulations (2005) (2nd ed.),” World Health Organization, Geneva, 2008. A. Talisuna, A. Yahaya, S. Rajatonirina, M. Stephen, A. Oke, A. Mpairwe, A. Diallo, E. Musa, D. Yota, F. Banza, R. Wango, N. Roberts, R. Sreedharan, N. Kandel, A. Rashford, L. Boulanger, Q. Huda, S. Chungong and Z. Yoti, “Joint external evaluation of the International Health Regulation (2005) capacities: current status and lessons learnt in the WHO African region.,” BMJ Global Health, vol. 4, no. 6, p. e001312., 2019. D. Satterthwaite, A. Sverdlik and D. Brown, “Revealing and responding to multiple health risks in informal settlements in Sub-Saharan African cities.,” Journal of Urban Health: Bulletin of the New York Academy of Medicine, vol. 96, no. 1, pp. 112-122, 2019. WHO, “Quarterly Emergency Preparedness and Response Report Q4 2023,” World Health Organization, Geneva, 2023. WHO, “Joint external evaluation tool: International Health Regulations (‎2005)‎ - third edition,” World Health Organization, Geneva, 2022. C. Chu, “Chu C. (2025). Global health security in the post-COVID-19 era: threats, preparation, and response.,” Osong public health and research perspectives, vol. 16, no. 2, pp. 116-125, 2025. S. Malik, A. Barlow and B. Johnson, “Reconceptualising health security in post-COVID-19 world,” BMJ Global Health, vol. 6, p. e006520, 2021. UNICEF, “Health & HIV,” UNICEF Zambia, 2021. [Online]. Available: https://www.unicef.org/zambia/health-hiv. [Accessed 2 July 2025]. M. Mwale, P. Chipimo, P. Kalubula, L. Hibusu, S. Mulima, K. Kapema and e. al., “Building resilience against cholera: lessons from the implementation of integrated community strategy for cholera control in Zambia,” BMJ Global Health. 2025;10:e017055., 2025. GHS Index, “Zambia country profile,” Global Health Security Index., 2021. [Online]. Available: https://ghsindex.org/country/zambia/. [Accessed 2 July 2025]. WHO, “Joint External Evaluation of IHR Core Capacities in Zambia - 2017 Mission Report,” World Health Organization, Geneva, 2017. WHO, “Joint external evaluation of IHR core capacities of Zambia: mission report, 2–6 October 2023,” World Health Organization (WHO), Geneva, 2025. MOH, “2022–2026 Strategic Plan: National Health – “Towards Attainment of Quality Universal Health Coverage Through Decentralisation”,” Republic of Zambia, Ministry of Health,, Lusaka, 2021. WHO, “WHO Zambia Country Cooperation Strategy 2024–2027,” World Health Organization (Regional Office for Africa), Brazzaville, 2024. IFRC, “Zambia: Anthrax Outbreak Final Report, DREF n° MDRZM020,” International Federation of Red Cross and Red Crescent Societies (IFRC), Geneva, 2025. C. B. Mandyata, L. K. Olowski and W. Mutale, “Challenges of implementing the integrated disease surveillance and response strategy in Zambia: a health worker perspective.,” BMC public health, vol. 17, no. 1, p. 746, 2017. K. Mwangilwa, C. Sialubanje and M. e. a. Chipoya, “Attention to COVID 19 pandemic resulted in increased measles cases and deaths in Zambia,” Trop Med Health, vol. 53, no. 59, 2025. M. Mwale, P. Masumbu, P. Chipimo, P. Sakubita, A. Phiri, K. Matanda, K. Mwangilwa, A. Carcelen, S. Mutembo, F. Masaninga, J. Sakala and P. Lugala, “Bridging immunization gaps: lessons from Zambia’s 2024 measles–rubella supplementary immunisation activity,” Front. Public Health., vol. 13, p. 1625514, 2025. WHO, “Chemicals of Public Health Concern in the WHO African Region,” World Health Organization Regional Office for Africa, Brazzaville, 2014. R. Khatri, A. Endalamaw, D. Erku and e. al., “Preparedness, impacts, and responses of public health emergencies towards health security: qualitative synthesis of evidence’,,” Archives of Public Health, vol. 81, no. 208, 2023. M. Nocci, M. Bortolin, A. Hertelendy and e. al, “Bridging the preparedness gap: a systematic review of recommended stockpile items for radiological and nuclear emergencies,” BMC Emergency Medicine, 25(1), 215, vol. 25(1), no. 215, 2025. J. Lee, R. Jansen, K. Sanderson and e. al., “Public health emergency preparedness for infectious disease emergencies: a scoping review of recent evidence.,” BMC Public Health, vol. 23, no. 420, 2023. T. Kamalrathne, D. Amaratunga, R. Haigh, L. Kodituwakku and C. Rupasinghe, “Epidemic and Pandemic Preparedness and Response in a Multi-Hazard Context: COVID-19 Pandemic as a Point of Reference.,” Int. J. Environ. Res. Public Health, vol. 21, no. 1238, 2024. D. McCoy, S. Roberts, S. Daoudi and J. Kennedy, “Global health security and the health-security nexus: principles, politics and praxis.,” BMJ Global Health., vol. 8, p. e013067, 2023. A. Lal, C. Wenham and J. Parkhurst, “Normative convergence between global health security and universal health coverage: a qualitative analysis of international health negotiations in the wake of COVID-19.,” Global Health, vol. 21, no. 5, 2025. N. Kandel, S. Chungong, A. Omaar and J. Xing, “Health security capacities in the context of COVID-19 outbreak: an analysis of International Health Regulations annual report data from 182 countries.,” The Lancet, vol. 395, no. 10229, p. 1047–1053, 2020. WHO, “WHO Benchmarks for Strengthening Health Emergency Capacities,” 2021. [Online]. Available: https://ihrbenchmark.who.int/document/introduction. World Bank, “Project Information Document: Zambia Pandemic Fund – Strengthening Health Emergency Preparedness in Zambia (P180828),” World Bank Group, Washington, DC, 2023. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8033745","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":581684302,"identity":"ea93db2a-092c-4f83-94ce-4985360ba499","order_by":0,"name":"Moses Mwale","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAqUlEQVRIiWNgGAWjYHACxgMMDDYMBkDWAaL1AFWmQbUkEK/lMFgLA1FadGckPzjwMed84nb2BsbDhT+I0GJ2I83g4MxttxN39hxgODyDGFvMbicYHObddjt3w40EhsM8xGlJ/3D477ZzJGnJMTjMuO0AKVruvyk42LstuX7DmYMNh3nSiNFy5vjGBz+32RkbHG8+/JnHhggtSICxgTT1o2AUjIJRMApwAwCwA0LE14JkRAAAAABJRU5ErkJggg==","orcid":"","institution":"World Health Organization","correspondingAuthor":true,"prefix":"","firstName":"Moses","middleName":"","lastName":"Mwale","suffix":""},{"id":581684303,"identity":"f4db1bce-2fb0-4996-95d2-4eba64278405","order_by":1,"name":"Gabriel Yali","email":"","orcid":"","institution":"The Zambia National Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Gabriel","middleName":"","lastName":"Yali","suffix":""},{"id":581684304,"identity":"b57e55b8-41c5-42a9-acb1-df23df62c77d","order_by":2,"name":"Peter Jay Chipimo","email":"","orcid":"","institution":"World Health Organization","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"Jay","lastName":"Chipimo","suffix":""},{"id":581684307,"identity":"9da536b0-63f7-4d6b-810d-b32691c03bf6","order_by":3,"name":"Precious Kalubula","email":"","orcid":"","institution":"World Health Organization","correspondingAuthor":false,"prefix":"","firstName":"Precious","middleName":"","lastName":"Kalubula","suffix":""},{"id":581684309,"identity":"6459e5fd-268b-4f39-80f5-d0617ca1c305","order_by":4,"name":"Kelvin Mwangilwa","email":"","orcid":"","institution":"The Zambia National Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Kelvin","middleName":"","lastName":"Mwangilwa","suffix":""},{"id":581684311,"identity":"60fd815f-4410-4b3b-856e-c79ebaaaea98","order_by":5,"name":"Nyuma Mbewe","email":"","orcid":"","institution":"World Health Organization","correspondingAuthor":false,"prefix":"","firstName":"Nyuma","middleName":"","lastName":"Mbewe","suffix":""},{"id":581684314,"identity":"fae67f1c-e13d-4b2e-9d9b-ff56834034f1","order_by":6,"name":"Paul Zulu","email":"","orcid":"","institution":"The Zambia National Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Paul","middleName":"","lastName":"Zulu","suffix":""},{"id":581684315,"identity":"bc181a81-0216-4fd0-a908-d4d21bf1b2bc","order_by":7,"name":"Davie Simwaba","email":"","orcid":"","institution":"The Zambia National Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Davie","middleName":"","lastName":"Simwaba","suffix":""},{"id":581684316,"identity":"2ec666f6-9ac9-40bd-8fb0-1798083d0f69","order_by":8,"name":"Freddie Masaninga","email":"","orcid":"","institution":"World Health Organization","correspondingAuthor":false,"prefix":"","firstName":"Freddie","middleName":"","lastName":"Masaninga","suffix":""},{"id":581684317,"identity":"16ef94f2-dda6-4c2c-bbbc-a068820582d1","order_by":9,"name":"Otipo Shikanga","email":"","orcid":"","institution":"World Health Organization","correspondingAuthor":false,"prefix":"","firstName":"Otipo","middleName":"","lastName":"Shikanga","suffix":""},{"id":581684318,"identity":"a3bab0e4-8a7f-491e-8091-ea9c1344b8fc","order_by":10,"name":"Nyambe Siyange","email":"","orcid":"","institution":"The Zambia National Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Nyambe","middleName":"","lastName":"Siyange","suffix":""},{"id":581684319,"identity":"1acb0f2f-30fe-40cf-9237-dd26141be946","order_by":11,"name":"Peter Clement Lasuba","email":"","orcid":"","institution":"World Health Organization","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"Clement","lastName":"Lasuba","suffix":""}],"badges":[],"createdAt":"2025-11-05 03:38:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8033745/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8033745/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101394793,"identity":"2bb2f822-8a87-460e-8426-b2d7073d151b","added_by":"auto","created_at":"2026-01-29 08:57:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":130369,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of Zambia's JEE scores by technical area, 2017 vs. 2023. Line graphs are faceted by category (Prevent, Detect, Respond, Other IHR-Related Hazards and Points of Entry), with each line representing one technical area. Upward trajectories indicate capacity improvements; downward trajectories indicate declines.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8033745/v1/90caa1d7a0266d494918701c.png"},{"id":101394828,"identity":"51edef71-8f78-464c-b88a-cc6fbe8c47d8","added_by":"auto","created_at":"2026-01-29 08:57:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":800864,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8033745/v1/045f7ef6-1d48-4617-8cc5-9271da36b18c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluating Zambia's Implementation of IHR Core Capacities: Insights from the 2017 and 2023 Joint External Evaluations","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe frequency and impact of public health emergencies have increased markedly in recent decades, as evidenced by global outbreaks such as SARS, H1N1, Ebola, COVID-19 and most recently Mpox. These events have exposed significant weaknesses in global health security systems and underscored the need for coordinated international frameworks to manage disease threats across borders [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In response, the International Health Regulations (IHR, 2005) were adopted by 196 countries as a legally binding instrument to strengthen core public health capacities for the prevention, detection, and response to events of international concern [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In the WHO African Region, the risk of epidemics remains high due to factors such as rapid population growth, unplanned urbanisation, climate change, cross-border mobility, and limited health system capacity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The region reports over 150 acute public health events annually, with cholera, measles, and viral haemorrhagic fevers among the most frequent [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. To operationalise the IHR, the region adopted the Integrated Disease Surveillance and Response (IDSR) strategy in the late 1990s and introduced the Joint External Evaluation (JEE) as part of the IHR Monitoring and Evaluation Framework. By 2019, 40 of 47 Member States had completed JEEs, revealing critical capacity gaps in areas such as antimicrobial resistance (AMR), biosafety, emergency operations, and chemical and radiation event preparedness [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe JEE is a voluntary, multisectoral assessment designed to evaluate country-level IHR capacities across 19 technical areas. The tool has evolved over time, with the latest edition (JEE 3.0) incorporating lessons from the COVID-19 pandemic to improve assessment accuracy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The pandemic further highlighted global weaknesses in IHR implementation, particularly in managing risks linked to urbanisation, AMR, climate change, and human\u0026ndash;animal interaction [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. As such, scholars have called for a reconceptualization of health security through a human security lens that emphasises equity, multisectoral action, and population-centred approaches [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Zambia, like many countries in the region, remains vulnerable to both endemic and emerging health threats. In recent years, the country has experienced concurrent outbreaks of cholera, measles, anthrax, and COVID-19, with rural areas disproportionately affected due to inadequate infrastructure, particularly unreliable electricity in over 60% of health facilities [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. To evaluate its readiness under the IHR, Zambia conducted its first JEE in 2017, which identified major gaps in risk communication, laboratory systems, and medical countermeasures [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In response, the Zambia National Public Health Institute (ZNPHI) was established in 2018 to enhance coordination and strengthen surveillance and response capacity. A second JEE, conducted in 2023, assessed progress made since 2017 and informed the development of Zambia\u0026rsquo;s National Action Plan for Health Security. Preliminary results indicate notable improvements in surveillance, emergency management, and points of entry, largely attributed to COVID-19-related investments and strengthened multisectoral coordination through ZNPHI [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Nonetheless, challenges remain in addressing AMR, immunisation coverage, and preparedness for chemical events.\u003c/p\u003e\u003cp\u003eThis study provides a comparative analysis of Zambia\u0026rsquo;s 2017 and 2023 JEE results, with the following objectives: (1) assess progress across the 19 IHR technical areas; (2) identify major improvements and persistent gaps; (3) examine contextual and institutional factors influencing performance; and (4) offer policy-relevant recommendations to strengthen Zambia\u0026rsquo;s health security architecture. This study adopts a health system resilience perspective, recognising that the ability to maintain and adapt core public health functions in the face of emergencies is central to IHR implementation. By analysing Zambia\u0026rsquo;s JEE results over time, we assess not only capacity levels but also the system\u0026rsquo;s adaptive performance across critical domains.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eThis study conducts a comparative analysis of Zambia\u0026rsquo;s 2017 and 2023 JEE scores to assess progress in implementing IHR core capacities. The JEE, developed by the World Health Organization (WHO), evaluates a country\u0026rsquo;s ability to prevent, detect, and respond to public health threats across 19 technical areas, categorized into Prevent, Detect, Respond, and Other IHR-Related Hazards and Points of Entry [6]. The 2017 JEE utilized the second edition of the JEE tool, while the 2023 JEE employed the third edition (JEE 3.0), which incorporated lessons from the COVID-19 pandemic, introducing new indicators such as gender equity and expanded antimicrobial resistance (AMR) metrics.\u003c/p\u003e\n\u003ch2\u003eData Sources\u003c/h2\u003e\n\u003cp\u003ePrimary data were sourced from the official 2017 and 2023 JEE reports for Zambia, accessed via the WHO JEE repository [12, 13]. These reports provide detailed assessments, including scores (1 = no capacity, 5 = sustainable capacity), recommendations, and contextual narratives from stakeholder consultations, site visits, and document reviews conducted during the JEE process. Supplementary data were obtained from national health policies (e.g., \u003cem\u003eNational Health Strategic Plan 2022\u0026ndash;2026 [14] and\u003c/em\u003e WHO country cooperation strategy [15]) to contextualize findings and explore influencing factors such as policy reforms and funding.\u003c/p\u003e\n\u003ch2\u003eHandling Changes in JEE Format\u003c/h2\u003e\n\u003cp\u003eThe transition from the second to the third edition of the JEE tool introduced changes in technical areas and indicators, increasing from 49 to 56 indicators while maintaining 19 technical areas\u0026nbsp;[6]. To ensure comparability, several steps were implemented. First, indicators that remained unchanged between the two editions, such as laboratory testing capacity, were directly compared to assess progress. Second, new JEE 3.0 indicators, such as gender equity in health emergency management, were mapped to related 2017 indicators like workforce development to ensure continuity. Finally, modifications in technical areas were categorized into splits, mergers, or removals. For example, \u0026apos;National legislation, policy, and financing\u0026apos; in the 2017 JEE was split into two separate technical areas in 2023: \u0026apos;Legal instruments\u0026apos; (covering legislation and policy) and \u0026apos;Financing\u0026apos; (covering funding mechanisms). To enable comparison, the 2023 scores for these two areas were combined using a weighted average: the mean of the two 2023 scores was calculated and compared against the single 2017 score. Conversely, when technical areas were merged, such as \u0026apos;Emergency preparedness\u0026apos; and \u0026apos;Emergency operations centre\u0026apos; becoming \u0026apos;Health emergency management\u0026apos; in 2023, the 2017 scores from both legacy areas were averaged to create a comparable baseline. This approach maintains the relative weight of each component while enabling valid trend analysis. Similarly, the dropped area \u0026apos;Reporting\u0026apos; was redistributed across related technical areas such as \u0026apos;IHR coordination\u0026apos; based on indicator content mapping documented in WHO\u0026apos;s JEE 3.0 transition guidance.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData Extraction and Verification\u003c/h2\u003e\n\u003cp\u003eData extraction involved a systematic review of JEE reports using a standardized Excel template to record scores, recommendations, and contextual notes for each technical area. Two researchers independently extracted data to ensure reliability, achieving an inter-rater reliability of 95%. Discrepancies were resolved through consensus discussions, guided by a third researcher when necessary. Verification was conducted by cross-referencing JEE data with national health plans, situation reports, and donor documents to confirm accuracy and consistency.\u003c/p\u003e\n\u003ch2\u003eAnalytical Framework\u003c/h2\u003e\n\u003cp\u003eThe analysis was structured around four components. First, a descriptive quantitative comparison was conducted in which JEE scores for 19 technical areas, grouped into Prevent, Detect, Respond, and Other IHR-Related Hazards and Points of Entry, were compared between 2017 and 2023 using Microsoft Excel and R (version 4.3.2). Absolute differences and percentage changes were calculated to illustrate directional progress, and descriptive statistics summarised changes at category and technical-area level. Second, a thematic review of the 2017 JEE recommendations was undertaken to identify implementation progress by 2023, focusing on recurrent themes in coordination, workforce development, and resource constraints. Third, a contextual analysis examined factors that may have influenced observed changes, including policy reforms (such as the establishment of the Zambia National Public Health Institute in 2018), external funding streams, and major public health events (for example, COVID-19 and the 2023 anthrax outbreak). Finally, a benchmarking exercise compared Zambia\u0026rsquo;s 2023 scores with WHO African Region and global reference values using published JEE summaries and regional analyses to situate Zambia\u0026rsquo;s performance relative to other countries in the Region.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eEthical Considerations\u003c/h2\u003e\n\u003cp\u003eThe study utilized publicly available JEE reports and adhered to WHO ethical guidelines for data handling. No primary data collection involving human subjects was conducted, negating the need for ethical approval.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eOverall JEE Score Comparison\u003c/h2\u003e\n\u003cp\u003eZambia\u0026rsquo;s JEE scores showed varied changes between 2017 and 2023 (Table 1). The Respond category recorded the largest improvement, with the average score increasing from 1.62 to 2.25 (+0.63; +38.5 %), reflecting substantial gains in emergency management and intersectoral coordination. The Detect category also improved slightly, rising from 2.70 to 2.90 (+0.20; +7.4 %), largely driven by strengthened surveillance systems. The Other IHR-Related Hazards and Points of Entry category increased from 1.83 to 2.07 (+0.24; +12.7 %), mainly due to enhanced capacity at points of entry. The Prevent category remained relatively stable, declining marginally from 2.39 to 2.37 (\u0026ndash;0.01; \u0026ndash;0.6 %). Figure 1 presents a comparison of JEE scores across all 19 technical areas between 2017 and 2023, organized by category.\u003c/p\u003e\n\u003cp\u003eWhile the magnitude of improvement varied across categories, the overall pattern indicates directional progress\u0026mdash;particularly in response and detection capacities, reflecting Zambia\u0026rsquo;s strengthened coordination and surveillance under the Zambia National Public Health Institute (ZNPHI). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e: Average JEE Scores by Category (2017 vs. 2023)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2017 score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2023 score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDifference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e% Change\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterpretation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrevent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0.6 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStable \u0026ndash; no meaningful change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDetect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e+0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e+7.4 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSmall improvement in detection capacity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRespond\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e+0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e+38.5 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModerate improvement, notably in emergency management and coordination\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOther IHR-Related Hazards and Points of Entry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e+0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e+12.7 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSlight improvement, driven by stronger border-health measures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: Changes are presented descriptively to illustrate directional progress. \u003cem\u003eSource: Authors\u0026rsquo; analysis based on WHO JEE reports (2017 and 2023).\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eTechnical Area Changes\u003c/h2\u003e\n\u003cp\u003eScores for individual technical areas within each category are presented in Table 2 and visualized in Figure 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePrevent:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eThe average score decreased from 2.39 to 2.37. Increases occurred in IHR coordination, communication, and advocacy (1.00 to 2.70, +1.7, 170.0%), national legislation, policy, and financing (2.00 to 2.50, +0.5, 25.0%), and biosafety and biosecurity (1.50 to 2.00, +0.5, 33.3%). Declines were observed in antimicrobial resistance (3.50 to 2.40, -1.1, -31.4%), immunization (4.00 to 2.70, -1.3, -32.5%), and zoonotic diseases (2.70 to 2.30, -0.4, -14.8%). Food safety remained unchanged (2.00).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDetect:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eThe average score increased from 2.70 to 2.90. Surveillance improved (2.40 to 3.70, +1.3, 54.2%), while workforce development declined (2.70 to 2.00, -0.7, -25.9%). The national laboratory system remained stable (3.00).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRespond:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eThe average score increased from 1.62 to 2.25. Improvements occurred in health emergency management (1.30 to 2.30, +1.0, 76.9%), linking public health and security authorities (1.00 to 2.00, +1.0, 100.0%), and health service provision and IPC (1.00 to 2.00, +1.0, 100.0%). Risk communication declined (3.20 to 2.70, -0.5, -15.6%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eOther IHR-Related Hazards and Points of Entry\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e:\u0026nbsp;\u003c/em\u003eThe average score increased from 1.83 to 2.07. Points of entry improved (1.00 to 3.70, +2.7, 270.0%), while chemical events (2.50 to 1.00, -1.5, -60.0%) and radiation emergencies (2.00 to 1.50, -0.5, -25.0%) declined.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e: JEE Scores by Category and Technical Area (2017 vs. 2023)\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTechnical Area\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e2017 Ave Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e2023 Ave Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePrevent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePrevent Average\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNational legislation, policy and financing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIHR coordination, communication and advocacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAntimicrobial resistance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eZoonotic diseases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFood safety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBiosafety and biosecurity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eImmunization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDetect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDetect Average\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNational laboratory system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSurveillance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHuman Resources and Workforce development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRespond\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRespond Average\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHealth emergency management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLinking public health and security authorities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHealth Service Provision and IPC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRisk communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOther IHR Hazards and Points of Entry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOther Average\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePoints of entry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eChemical events\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRadiation emergencies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote\u003c/em\u003e: Scores range from 1 to 5, with higher scores indicating greater capacity. Category averages are the mean of technical area scores within each category, rounded to two decimal places. \u0026nbsp;Category averages are presented descriptively; no formal significance testing was conducted.\u003c/p\u003e\n\u003cp\u003eA line graph, faceted by category, shows score changes for each technical area, highlighting increases in IHR coordination, surveillance, and points of entry, and declines in AMR, immunization, and chemical events (figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative Thematic Analysis\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;To complement the quantitative results, qualitative thematic analysis was undertaken to contextualise observed trends. Thematic review of recommendations from the 2017 JEE identified three recurrent themes reflecting Zambia\u0026rsquo;s progress by 2023.\u003cbr\u003eFirst, establishment of the Zambia National Public Health Institute (ZNPHI) markedly improved intersectoral coordination and emergency response, aligning with gains in the \u003cem\u003eRespond\u003c/em\u003e category. Second, partial implementation of laboratory system and workforce reforms enhanced surveillance capacity but left persistent shortages in trained personnel, echoing the moderate improvement observed under \u003cem\u003eDetect\u003c/em\u003e. Third, limited domestic financing and weak multisectoral collaboration constrained full implementation of antimicrobial-resistance, immunisation, and chemical-event preparedness activities, areas showing score declines. Overall, the qualitative findings corroborate the quantitative results, highlighting both institutional progress and remaining structural bottlenecks in health-security capacity building.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe comparison of Zambia\u0026rsquo;s 2017 and 2023 JEE scores, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, highlights both progress and persistent gaps in IHR core capacities. The analysis addressed the objectives of examining changes across technical areas, identifying improvements and setbacks, and interpreting these changes in the context of Zambia\u0026rsquo;s health security architecture, which operates in a region where infectious diseases remain a major cause of mortality. Three overarching patterns emerge from the results. First, response capacities improved markedly (+\u0026thinsp;38.5%), reflecting strengthened emergency coordination and management systems. Second, detection capacities showed modest but meaningful gains (+\u0026thinsp;7.4%), particularly in surveillance. Third, prevention capacities remained largely stagnant or declined in critical areas, notably antimicrobial resistance (-31.4%) and immunization (-32.5%). These divergent trajectories suggest uneven progress across the IHR framework, warranting closer examination of category-specific drivers and constraints.\u003c/p\u003e\u003cp\u003eThe notable improvement in the Respond category is consistent with strengthened emergency management and multisectoral coordination led by the Zambia National Public Health Institute (ZNPHI), established in 2018. ZNPHI has coordinated responses to cholera, measles, anthrax, and mpox, contributing to faster detection, escalation, and management of public health events [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These gains suggest that Zambia is now better able to manage acute infectious threats. However, gaps in multi-hazard preparedness remain, particularly for chemical events and other non-communicable hazards such as radiation emergencies, which are increasingly relevant in the context of industrial growth and climate-related risks. The increase observed in the Detect category, particularly in surveillance, reflects the continued implementation of the IDSR system and the consolidation of laboratory and event reporting functions under ZNPHI [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Stronger surveillance capacity is critical in a subregional context characterised by highly mobile populations and cross-border disease transmission in Southern Africa. The marked improvement at points of entry is consistent with COVID-19-era investment in border screening infrastructure and protocols, which has been prioritised across the WHO African Region to limit cross-border spread.\u003c/p\u003e\u003cp\u003eBy contrast, declines in antimicrobial resistance (AMR), immunisation, and chemical event preparedness indicate structural weaknesses. Setbacks in AMR likely reflect limited surveillance coverage, weak laboratory stewardship systems, and incomplete One Health coordination between human, animal, and environmental health sectors [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The decline in immunisation capacity is consistent with documented COVID-19-era disruptions to routine vaccination and follow-up services in Zambia and the region [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Reduced capacity for chemical event management likely reflects underinvestment in specialised technical preparedness during a period in which national and partner funding was channelled primarily to infectious disease response [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. These declines warrant particular attention, as they occurred despite overall system strengthening in other domains and illustrate critical trade-offs in health emergency management: surge capacity for acute threats can inadvertently weaken foundational prevention programmes when systems lack sufficient redundancy or ring-fenced resources [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Similarly, the focus on infectious disease surveillance and response diverted attention and technical resources away from chemical and radiation emergency preparedness, which require specialized equipment, training, and protocols distinct from those used for biological threats [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. These trade-offs highlight the tension between vertical (disease-specific) and horizontal (systems-wide) approaches to health security [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and underscore the need for integrated planning that protects core prevention functions even during emergency response periods [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBenchmarking Zambia's 2023 scores against regional and global patterns shows mixed performance. Zambia's Detect capacity (2.90), driven by surveillance (3.70), exceeds the WHO African Region average and reflects pandemic-era investments in disease detection systems that have strengthened capacity across the continent. This continues a historical pattern in which detection has generally outpaced prevention in the region [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], a trend that persists in the post-COVID-19 era. However, Zambia's Prevent capacity (2.37) and preparedness for chemical events remain weak, echoing a continental challenge in which prevention and non-infectious hazard management continue to lag behind outbreak response capabilities. Compared with global trends, Zambia's profile still falls below the proportion of countries reporting more mature prevention and response capacity, indicating the need to build sustained readiness beyond infectious disease control [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This pattern of stronger infectious disease response relative to other hazards reflects both funding architecture and risk perception: international financing mechanisms and technical assistance have historically prioritized epidemic-prone diseases, while domestic capacity for chemical and radiation events remains chronically under-resourced [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The result is an asymmetric preparedness profile that, while appropriate to Zambia's epidemiological context, may leave the country vulnerable to industrial accidents, environmental contamination, and other non-infectious hazards as urbanization and mining activities expand.\u003c/p\u003e\u003cp\u003eThe qualitative thematic analysis supports these interpretations. First, the establishment and mandate of ZNPHI improved coordination and emergency management, explaining the gains in Respond and in surveillance under Detect. Second, partial implementation of laboratory and workforce reforms contributed to surveillance improvements but did not fully address workforce shortages, which remain critical for sustained capacity, particularly outside urban centres. Third, limited domestic financing and fragmented multisectoral engagement constrained progress in antimicrobial resistance, immunisation, and chemical event preparedness. These thematic findings show that Zambia\u0026rsquo;s progress has been institutionally driven, but also remains vulnerable to funding structure, workforce availability, and scope of mandate.\u003c/p\u003e\u003cp\u003eImplementation considerations are already visible in Zambia\u0026rsquo;s National Action Plan for Health Security (NAPHS). The WHO IHR Benchmarking Tool aims to move technical areas at levels 1\u0026ndash;2 toward at least level 3 (\u0026ldquo;developed capacity\u0026rdquo;), with a focus on realistic, sequenced actions [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Zambia has aligned its NAPHS with this approach, supported by catalytic financing from mechanisms such as the Pandemic Fund and the Global Fund, which have funded emergency operations, workforce development, biosafety, and simulation exercises [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Although Zambia\u0026rsquo;s aggregate scores remain below global averages in prevention and multi-hazard response, this targeted investment pathway indicates a structured route for progressive capacity strengthening [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis analysis has limitations. First, score comparisons are descriptive and reflect directional change rather than statistically tested differences; this approach is consistent with the ordinal nature of JEE scoring. Second, differences in tool editions between 2017 and 2023 required indicator mapping, which may introduce some classification uncertainty despite systematic alignment. Third, reliance on national JEE reports risks underrepresenting subnational and community-level capacities. Fourth, JEE assessments involve a degree of self-reporting by host countries, which may introduce social desirability bias or optimistic scoring, particularly in areas where demonstrable evidence is limited. The external evaluation process and multisectoral validation mechanisms partially mitigate this risk, but the potential for overestimation of capacity or conversely, underreporting where systems lack documentation, should be acknowledged. These limitations were mitigated through triangulation with national policy documents and WHO strategic reports.\u003c/p\u003e\u003cp\u003eFuture work should assess how national-level capacity translates into subnational readiness, especially in provinces and districts with recurrent outbreaks and limited infrastructure. Further assessment of non-infectious hazards \u0026mdash; including chemical and radiation events \u0026mdash; is also critical, given their low-capacity scores but high potential impact on both workers and surrounding communities.\u003c/p\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eRecommendations\u003c/h2\u003e\u003cp\u003eTo strengthen Zambia\u0026rsquo;s IHR core capacities, the following prioritized, actionable recommendations are proposed, aligned with the National Health Strategic Plan 2022\u0026ndash;2026:\u003c/p\u003e\u003cp\u003eHigh-priority actions:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eRestore immunisation capacity (Prevent \u0026ndash; Immunisation): Implement targeted community outreach and catch-up vaccination programmes, with a focus on high-risk and hard-to-reach populations, to reverse declines in routine immunisation performance.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eStrengthen antimicrobial resistance (Prevent \u0026ndash; Antimicrobial Resistance): Develop and operationalise a national One Health antimicrobial resistance surveillance and stewardship framework, in collaboration with Africa CDC, to improve real-time detection and coordinated response across human, animal, and environmental sectors.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eImprove readiness for chemical events (Other \u0026ndash; Chemical Events): Invest in specialised training, equipment, and standard operating procedures for chemical incident detection and response, working with technical partners (e.g. UKHSA, USAID) to build dedicated national and subnational response capacity.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eMedium-priority actions:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eExpand and retain the health security workforce (Detect \u0026ndash; Workforce Development): Scale targeted workforce development and retention strategies, especially outside Lusaka and Copperbelt, to address persistent shortages in trained epidemiologists, laboratory personnel, and rapid response staff.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eReinforce risk communication (Respond \u0026ndash; Risk Communication): Strengthen public risk communication and community engagement systems, including digital and local-language channels, to maintain public trust during outbreaks and other emergencies.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIntegrate zoonotic disease surveillance (Prevent \u0026ndash; Zoonotic Diseases): Formalise data-sharing and joint investigation mechanisms between veterinary and public health authorities, building on the recent multisectoral response to anthrax.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eLong-term systems measures\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eInstitutionalise IHR financing and accountability (Governance / IHR Coordination): Update public health legislation and financing arrangements to embed IHR core capacity funding lines in domestic budgets, reducing dependence on external partners.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eCreate a national IHR / health security task force (IHR Coordination): Establish a permanent, ZNPHI-led multisectoral mechanism to monitor implementation of the National Action Plan for Health Security (NAPHS) and maintain coordination gains beyond emergency periods.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAddress non-infectious hazard preparedness (Other \u0026ndash; Chemical Events, Radiation Emergencies): Develop and test multi-hazard preparedness plans for chemical and radiation events, aligned with the Sendai Framework, with simulation exercises and after-action reviews integrated into routine preparedness cycles.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eZambia\u0026rsquo;s comparison of JEE results from 2017 to 2023 shows measurable gains in response capacity, surveillance, and points of entry, alongside ongoing weaknesses in antimicrobial resistance, immunisation, multi-hazard preparedness, and workforce depth. These patterns reflect targeted improvements in coordination and emergency management, particularly following the establishment of the Zambia National Public Health Institute, but also reveal areas in which progress has not kept pace, especially for chemical events and other non-infectious hazards.\u003c/p\u003e\u003cp\u003eThe findings directly inform Zambia\u0026rsquo;s National Action Plan for Health Security and illustrate how countries can translate JEE results into sequenced capacity-building investments under the International Health Regulations. They also underscore that sustaining progress will require not only external financing and emergency surge capacity, but also long-term domestic investment in workforce, governance, and preparedness systems. Strengthening these foundations is essential if Zambia is to manage both recurrent infectious outbreaks and emerging non-infectious threats, and to contribute reliably to regional and global health security in a way that is equitable and people centred.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This study received no specific funding. The authors were supported by their respective institutions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;We thank the Zambia National Public Health Institute (ZNPHI) and the Ministry of Health Zambia for providing access to JEE reports and related data. We acknowledge the World Health Organization (WHO) for facilitating JEE assessments in the African Region.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The data used in this study, including Zambia\u0026rsquo;s 2017 and 2023 JEE reports, are publicly available through the WHO JEE repository.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMoses Mwale: Conceptualisation, Methodology, Formal analysis, Data curation, Visualisation, Writing \u0026ndash; original draft, Writing \u0026ndash; review and editing.\u003cbr\u003e\u0026nbsp;Gabriel Yali: Conceptualisation, Methodology, Data acquisition, Validation, Writing \u0026ndash; review and editing.\u003cbr\u003e\u0026nbsp;Peter Jay Chipimo: Supervision, Validation, Writing \u0026ndash; review and editing.\u003cbr\u003e\u0026nbsp;Precious Kalubula: Validation, Writing \u0026ndash; review and editing.\u003cbr\u003e\u0026nbsp;Kelvin Mwangilwa: Validation, Writing \u0026ndash; review and editing.\u003cbr\u003e\u0026nbsp;Nyuma Mbewe: Investigation, Writing \u0026ndash; review and editing.\u003cbr\u003e\u0026nbsp;Paul Zulu: Data acquisition, Project administration, Writing \u0026ndash; review and editing.\u003cbr\u003e\u0026nbsp;Davie Simwaba: Validation, Writing \u0026ndash; review and editing.\u003cbr\u003e\u0026nbsp;Freddie Masaninga: Resources, Writing \u0026ndash; review and editing.\u003cbr\u003e\u0026nbsp;O-tipo Shikanga: Supervision, Writing \u0026ndash; review and editing.\u003cbr\u003e\u0026nbsp;Nyambe Siyange: Validation, Writing \u0026ndash; review and editing.\u003cbr\u003e\u0026nbsp;Peter Clement Lasuba: Supervision, Resources, Project administration, Writing \u0026ndash; review and editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not require ethical approval, as it involved the analysis of data obtained from publicly available JEE reports and did not involve human participants, identifiable personal data, or biological samples. No primary data were collected. Therefore, consent to participate was not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo individual identifying information is included in this manuscript. Consent to publish was therefore not required.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eS. Moon, D. Sridhar, M. Pate, A. Jha, C. Clinton, S. Delaunay, V. Edwin, M. Fallah, D. Fidler, L. Garrett, E. Goosby, L. Gostin, D. Heymann, K. Lee, G. Leung, J. Morrison, J. Saavedra, M. Tanner, J. Leigh and B. Hawkins, \u0026ldquo;Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola.,\u0026rdquo; \u003cem\u003eThe Lancet,\u0026nbsp;\u003c/em\u003evol. 386, no. 10009, p. 2204\u0026ndash;2221, 2015.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWHO, \u0026ldquo;International Health Regulations (2005) (2nd ed.),\u0026rdquo; World Health Organization, Geneva, 2008.\u003c/li\u003e\n \u003cli\u003eA. Talisuna, A. Yahaya, S. Rajatonirina, M. Stephen, A. Oke, A. Mpairwe, A. Diallo, E. Musa, D. Yota, F. Banza, R. Wango, N. Roberts, R. Sreedharan, N. Kandel, A. Rashford, L. Boulanger, Q. Huda, S. Chungong and Z. Yoti, \u0026ldquo;Joint external evaluation of the International Health Regulation (2005) capacities: current status and lessons learnt in the WHO African region.,\u0026rdquo; \u003cem\u003eBMJ Global Health,\u0026nbsp;\u003c/em\u003evol. 4, no. 6, p. e001312., 2019.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eD. Satterthwaite, A. Sverdlik and D. Brown, \u0026ldquo;Revealing and responding to multiple health risks in informal settlements in Sub-Saharan African cities.,\u0026rdquo; \u003cem\u003eJournal of Urban Health: Bulletin of the New York Academy of Medicine,\u0026nbsp;\u003c/em\u003evol. 96, no. 1, pp. 112-122, 2019.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWHO, \u0026ldquo;Quarterly Emergency Preparedness and Response Report Q4 2023,\u0026rdquo; World Health Organization, Geneva, 2023.\u003c/li\u003e\n \u003cli\u003eWHO, \u0026ldquo;Joint external evaluation tool: International Health Regulations (\u0026lrm;2005)\u0026lrm; - third edition,\u0026rdquo; World Health Organization, Geneva, 2022.\u003c/li\u003e\n \u003cli\u003eC. Chu, \u0026ldquo;Chu C. (2025). Global health security in the post-COVID-19 era: threats, preparation, and response.,\u0026rdquo; \u003cem\u003eOsong public health and research perspectives,\u0026nbsp;\u003c/em\u003evol. 16, no. 2, pp. 116-125, 2025.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eS. Malik, A. Barlow and B. Johnson, \u0026ldquo;Reconceptualising health security in post-COVID-19 world,\u0026rdquo; \u003cem\u003eBMJ Global Health,\u0026nbsp;\u003c/em\u003evol. 6, p. e006520, 2021.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eUNICEF, \u0026ldquo;Health \u0026amp; HIV,\u0026rdquo; UNICEF Zambia, 2021. [Online]. Available: https://www.unicef.org/zambia/health-hiv. [Accessed 2 July 2025].\u003c/li\u003e\n \u003cli\u003eM. Mwale, P. Chipimo, P. Kalubula, L. Hibusu, S. Mulima, K. Kapema and e. al., \u0026ldquo;Building resilience against cholera: lessons from the implementation of integrated community strategy for cholera control in Zambia,\u0026rdquo; \u003cem\u003eBMJ Global Health. 2025;10:e017055.,\u0026nbsp;\u003c/em\u003e2025.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGHS Index, \u0026ldquo;Zambia country profile,\u0026rdquo; Global Health Security Index., 2021. [Online]. Available: https://ghsindex.org/country/zambia/. [Accessed 2 July 2025].\u003c/li\u003e\n \u003cli\u003eWHO, \u0026ldquo;Joint External Evaluation of IHR Core Capacities in Zambia - 2017 Mission Report,\u0026rdquo; World Health Organization, Geneva, 2017.\u003c/li\u003e\n \u003cli\u003eWHO, \u0026ldquo;Joint external evaluation of IHR core capacities of Zambia: mission report, 2\u0026ndash;6 October 2023,\u0026rdquo; World Health Organization (WHO), Geneva, 2025.\u003c/li\u003e\n \u003cli\u003eMOH, \u0026ldquo;2022\u0026ndash;2026 Strategic Plan: National Health \u0026ndash; \u0026ldquo;Towards Attainment of Quality Universal Health Coverage Through Decentralisation\u0026rdquo;,\u0026rdquo; Republic of Zambia, Ministry of Health,, Lusaka, 2021.\u003c/li\u003e\n \u003cli\u003eWHO, \u0026ldquo;WHO Zambia Country Cooperation Strategy 2024\u0026ndash;2027,\u0026rdquo; World Health Organization (Regional Office for Africa), Brazzaville, 2024.\u003c/li\u003e\n \u003cli\u003eIFRC, \u0026ldquo;Zambia: Anthrax Outbreak Final Report, DREF n\u0026deg; MDRZM020,\u0026rdquo; International Federation of Red Cross and Red Crescent Societies (IFRC), Geneva, 2025.\u003c/li\u003e\n \u003cli\u003eC. B. Mandyata, L. K. Olowski and W. Mutale, \u0026ldquo;Challenges of implementing the integrated disease surveillance and response strategy in Zambia: a health worker perspective.,\u0026rdquo; \u003cem\u003eBMC public health,\u0026nbsp;\u003c/em\u003evol. 17, no. 1, p. 746, 2017.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eK. Mwangilwa, C. Sialubanje and M. e. a. Chipoya, \u0026ldquo;Attention to COVID 19 pandemic resulted in increased measles cases and deaths in Zambia,\u0026rdquo; \u003cem\u003eTrop Med Health,\u0026nbsp;\u003c/em\u003evol. 53, no. 59, 2025.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eM. Mwale, P. Masumbu, P. Chipimo, P. Sakubita, A. Phiri, K. Matanda, K. Mwangilwa, A. Carcelen, S. Mutembo, F. Masaninga, J. Sakala and P. Lugala, \u0026ldquo;Bridging immunization gaps: lessons from Zambia\u0026rsquo;s 2024 measles\u0026ndash;rubella supplementary immunisation activity,\u0026rdquo; \u003cem\u003eFront. Public Health.,\u0026nbsp;\u003c/em\u003evol. 13, p. 1625514, 2025.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWHO, \u0026ldquo;Chemicals of Public Health Concern in the WHO African Region,\u0026rdquo; World Health Organization Regional Office for Africa, Brazzaville, 2014.\u003c/li\u003e\n \u003cli\u003eR. Khatri, A. Endalamaw, D. Erku and e. al., \u0026ldquo;Preparedness, impacts, and responses of public health emergencies towards health security: qualitative synthesis of evidence\u0026rsquo;,,\u0026rdquo; \u003cem\u003eArchives of Public Health,\u0026nbsp;\u003c/em\u003evol. 81, no. 208, 2023.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eM. Nocci, M. Bortolin, A. Hertelendy and e. al, \u0026ldquo;Bridging the preparedness gap: a systematic review of recommended stockpile items for radiological and nuclear emergencies,\u0026rdquo; \u003cem\u003eBMC Emergency Medicine, 25(1), 215,\u0026nbsp;\u003c/em\u003evol. 25(1), no. 215, 2025.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eJ. Lee, R. Jansen, K. Sanderson and e. al., \u0026ldquo;Public health emergency preparedness for infectious disease emergencies: a scoping review of recent evidence.,\u0026rdquo; \u003cem\u003eBMC Public Health,\u0026nbsp;\u003c/em\u003evol. 23, no. 420, 2023.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eT. Kamalrathne, D. Amaratunga, R. Haigh, L. Kodituwakku and C. Rupasinghe, \u0026ldquo;Epidemic and Pandemic Preparedness and Response in a Multi-Hazard Context: COVID-19 Pandemic as a Point of Reference.,\u0026rdquo; \u003cem\u003eInt. J. Environ. Res. Public Health,\u0026nbsp;\u003c/em\u003evol. 21, no. 1238, 2024.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eD. McCoy, S. Roberts, S. Daoudi and J. Kennedy, \u0026ldquo;Global health security and the health-security nexus: principles, politics and praxis.,\u0026rdquo; \u003cem\u003eBMJ Global Health.,\u0026nbsp;\u003c/em\u003evol. 8, p. e013067, 2023.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eA. Lal, C. Wenham and J. Parkhurst, \u0026ldquo;Normative convergence between global health security and universal health coverage: a qualitative analysis of international health negotiations in the wake of COVID-19.,\u0026rdquo; \u003cem\u003eGlobal Health,\u0026nbsp;\u003c/em\u003evol. 21, no. 5, 2025.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eN. Kandel, S. Chungong, A. Omaar and J. Xing, \u0026ldquo;Health security capacities in the context of COVID-19 outbreak: an analysis of International Health Regulations annual report data from 182 countries.,\u0026rdquo; \u003cem\u003eThe Lancet,\u0026nbsp;\u003c/em\u003evol. 395, no. 10229, p. 1047\u0026ndash;1053, 2020.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWHO, \u0026ldquo;WHO Benchmarks for Strengthening Health Emergency Capacities,\u0026rdquo; 2021. [Online]. Available: https://ihrbenchmark.who.int/document/introduction.\u003c/li\u003e\n \u003cli\u003eWorld Bank, \u0026ldquo;Project Information Document: Zambia Pandemic Fund \u0026ndash; Strengthening Health Emergency Preparedness in Zambia (P180828),\u0026rdquo; World Bank Group, Washington, DC, 2023.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"International Health Regulations, Joint External Evaluation, health security, Zambia, surveillance, antimicrobial resistance, emergency preparedness, public health capacity","lastPublishedDoi":"10.21203/rs.3.rs-8033745/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8033745/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eZambia\u0026rsquo;s commitment to the International Health Regulations (IHR, 2005) is periodically assessed through Joint External Evaluations (JEEs) across 19 technical areas. This study compares Zambia\u0026rsquo;s 2017 and 2023 JEE results to assess progress in IHR core capacities. We extracted scores from official JEE reports and undertook descriptive comparisons by category (Prevent, Detect, Respond, and Other IHR-related hazards and Points of Entry), complemented by a brief thematic review of recommendations. Differences in JEE tool editions were addressed through systematic indicator mapping to ensure comparability.\u003c/p\u003e\u003cp\u003eBetween 2017 and 2023, Zambia recorded the largest gains in the Respond category (mean 1.62 to 2.25; +0.63 points, +\u0026thinsp;38.5%). Marked improvements were observed in IHR coordination (1.00 to 2.70; +170.0%), surveillance (2.40 to 3.70; +54.2%), and points of entry (1.00 to 3.70; +270.0%). Detect improved modestly (2.70 to 2.90; +7.4%), while Prevent was essentially unchanged (2.39 to 2.37; \u0026minus;0.8%). Notable declines were seen in antimicrobial resistance (3.50 to 2.40; \u0026minus;31.4%), immunisation (4.00 to 2.70; \u0026minus;32.5%), and chemical events (2.50 to 1.00; \u0026minus;60.0%). Qualitative findings suggest strengthened coordination via the Zambia National Public Health Institute (ZNPHI), but persistent gaps in antimicrobial resistance and chemical-event preparedness.\u003c/p\u003e\u003cp\u003eOverall, Zambia has advanced emergency response and surveillance capacities, likely reflecting ZNPHI establishment and COVID-19 investments, yet weaknesses remain in antimicrobial resistance, routine immunisation, and chemical hazard management. Priorities include restoring immunisation coverage, expanding One Health antimicrobial resistance surveillance, and improving chemical event readiness. These insights can guide updates to the National Action Plan for Health Security and resource allocation in resource-constrained settings.\u003c/p\u003e","manuscriptTitle":"Evaluating Zambia's Implementation of IHR Core Capacities: Insights from the 2017 and 2023 Joint External Evaluations","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-29 08:56:34","doi":"10.21203/rs.3.rs-8033745/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f2206e87-c1ae-4b6e-b1c4-22d9a4f97ed4","owner":[],"postedDate":"January 29th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-29T08:56:35+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-29 08:56:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8033745","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8033745","identity":"rs-8033745","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}