Barriers

Using an incident management system (IMS) posed challenges when running a PHEOC. Two studies noted a lack of understanding of the incident management system structure and its related functions. ^{Reference Su, Wu and Lee45,Reference Otu, Ameh and Osifo-Dawodu54} For example, Kim et al. ^{Reference Kim, Oh and Wang47} found that during a MERS-CoV outbreak in South Korea, there were “varying levels of understanding of an Incident Control System” that made it difficult for the ICS to function as expected. ^{Reference Kim, Oh and Wang47} Brooks et al. ^{Reference Brooks, Pinto and Gill26} also noted that several countries experienced challenges related to implementing the IMS when responding to EVD in West Africa in 2014. For example, the EOC in Guinea cited a lack of standardized definitions within the IMS, which led to different interpretations of indicators and roles. ^{Reference Brooks, Pinto and Gill26}

The agency in charge of coordinating the IMS was also cited as a factor impacting the running of a PHEOC. For example, during the Sierra Leone EVD outbreak (2013–2016), there were different institutions coordinating the IMS throughout the response. This often led to tensions between local agencies and with agencies from abroad. ^{Reference Ross29} Two studies also described the challenge of the IMS coordinator/commander having insufficient mandate to hold others to account or to make decisions without being challenged by other authorities, which made it difficult to progress decisions. ^{Reference Ross29,Reference Otu, Ameh and Osifo-Dawodu54}

Enablers

Seven studies identified the importance of using an incident management system to enable clear coordination and to optimize the efficiency of a PHEOC. ^{Reference Bousso19,Reference Olu, Lamunu and Chimbaru28,Reference Ross29,Reference Hinjoy, Tsukayama and Chuxnum40,Reference Delaney41,Reference Su, Wu and Lee45,Reference Kim, Oh and Wang47} An incident management system was found to assist with prompt decision making, helped reduce duplication, and encouraged the development of plans to clarify PHEOC functions, roles, and responsibilities. ^{Reference Mobula, Samaha and Yao18,Reference Brooks, Pinto and Gill26,Reference Olu, Lamunu and Chimbaru28,Reference Alabbadi and Al-Masaeed30,Reference Su, Wu and Lee45,Reference Kim, Oh and Wang47} Having 1 unified command with support functions also helped integrate the incident management system with the public health functions. ^{Reference Kim, Oh and Wang47}

Barriers

Three studies cited having an inadequate planning framework to assist with preparing and responding to a public health emergency. ^{Reference Ross29,Reference Alabbadi and Al-Masaeed30,Reference Otu, Ameh and Osifo-Dawodu54} In addition, when responding to an EVD outbreak, the Nigerian national PHEOC did not have any formal agreements within the teams working in the IMS, which led to problems of ownership, accountability, and challenges with setting working limits. ^{Reference Otu, Ameh and Osifo-Dawodu54}

Enablers

Several studies noted the importance of having clear public health emergency plans, policies and procedures, and a legal mandate to operate the PHEOC to enable the smooth running of a PHEOC. ^{Reference Bousso19,Reference Balajee, Pasi and Etoundi21,Reference Brooks, Pinto and Gill26,Reference Kim, Oh and Wang47} This included a plan with clearly articulated criteria for activating a PHEOC and tailoring the plan to a country’s existing legislative framework. Having a legally binding plan was also suggested to create a strong foundation for seeking additional funds, resources, and support in the event of a public health emergency. ^{Reference Bousso19,Reference Balajee, Pasi and Etoundi21,Reference Brooks, Pinto and Gill26,Reference Kim, Oh and Wang47} Long-term planning of human, technical, and financial resources and planning for how the PHEOC would be used during “peace time” was also important, particularly in consideration of sustaining the PHEOC beyond a public health emergency response. ^{Reference Aceng, Ario and Muruta17,53}

Barriers

Communication within and external to the PHEOC was noted by several studies as having an impact on the effective running of a PHEOC. ^{Reference Standley, MacDonald and Attal-Juncqua22,Reference Olu, Lamunu and Chimbaru28,Reference Yang, Noh and Song49,Reference Yang, Chen and Su55} For example, during the MERS-CoV outbreak in South Korea (2015), there was no crisis information sharing system, which resulted in a lack of communication between the different levels of government and across agencies. Olu et al. ^{Reference Olu, Lamunu and Chimbaru28} also cited a lack of data sharing across stakeholders and within internal government departments, making it hard to ascertain situational awareness and implement an appropriate response. ^{Reference Olu, Lamunu and Chimbaru28} Information sharing between the PHEOC and the public was also problematic during the MERS-CoV outbreak in South Korea, with inconsistent messaging and communication lacking transparency, resulting in community mistrust. ^{Reference Yang, Noh and Song49}

Enablers

“At nearly every level, personalities and personal relationships appeared to be key to the functioning of the PHEOC.” ^{Reference Standley, MacDonald and Attal-Juncqua22} Five studies discussed the importance of clear communication between the PHEOC and external agencies, including the sharing of tools, resources, and information amongst partners to enable buy-in, mutual ownership, political leverage, and seamless collaboration. ^{Reference Mobula, Samaha and Yao18,Reference Balajee, Pasi and Etoundi21–Reference Vaz, Mkanda and Banda23,Reference Olu, Lamunu and Chimbaru28} Having an official spokesperson to engage and share information with regional and international organizations was important to enhance interagency communication. ^{Reference Hinjoy, Tsukayama and Chuxnum40} Regular meetings with partners, including developing a “cooperative agreement” to support innovative and collaborative response activities, were cited as an important aspect of enhancing communication and cooperation. ^{Reference Standley, MacDonald and Attal-Juncqua22} Three studies noted the importance of strong internal communication and cooperation within a PHEOC to enable strategic decision-making, to support efficient mobilization of resources, and to ensure timely dissemination of risk communication messages. ^{Reference Standley, MacDonald and Attal-Juncqua22,Reference Ross29,Reference Kim, Oh and Wang47} Kim et al. ^{Reference Kim, Oh and Wang47} also noted that having 1 person in charge enabled a clear communication mechanism to reduce conflict over critical issues, such as when to release risk communication messages to an affected community. ^{Reference Kim, Oh and Wang47}

Barriers

Many studies found managing data and information within a PHEOC to be a challenge. ^{20,Reference Hinjoy, Tsukayama and Chuxnum40,Reference Huang44,Reference Su, Wu and Lee45} The “fragmented” nature of data streams, including surveillance data collected through multiple sources, made it hard for the timely detection of outbreaks and for accurate situational analysis. ^{Reference Balajee, Pasi and Etoundi21} Several studies highlighted issues relating to accessing up-to-date, comprehensive information detailing the availability and tracking of resources and assets. ^{Reference Olu, Lamunu and Chimbaru28–Reference Alabbadi and Al-Masaeed30} Another key barrier to data coordination was having different data collection guidelines and reporting formats across different agencies, making it hard for the PHEOC to collate this information in a timely manner. ^{Reference Olu, Lamunu and Chimbaru28,Reference Ross29}

Enablers

Having access to appropriate technology within a PHEOC was found to enhance the timely detection, collection, and interpretation of data essential to an efficient public health emergency response. ^{Reference Mobula, Samaha and Yao18,Reference Vaz, Mkanda and Banda23} “Investing early” in the most appropriate technology to collect and manage information, including a database with information on previous public health emergencies and lessons learnt, was suggested as an important part of preparing for a public health emergency. ^{Reference Nyenswah, Kateh and Bawo27,Reference Alabbadi and Al-Masaeed30} One study noted the importance of having a national inventory system to ensure the prompt mobilization and deployment of resources in the event of a public health emergency. ^{Reference Olu, Lamunu and Chimbaru28} Another study suggested consideration of innovations such as artificial-intelligence-based information and communication technology to explore the potential to enhance surveillance and outbreak forecasting. “Successful innovation along with local adaptations and experience have to be quickly and widely shared with global society to overcome common challenges.” ^{Reference Yang, Noh and Song49}

Barriers

Many PHEOCs, particularly in low resource settings, found building and sustaining a PHEOC workforce to be a challenge. The constant turnover of staff and the continuity of operations for staff who moved from other departments often led to gaps in the implementation of tasks within the PHEOC and in other public health programs. Having a small workforce made it harder to upscale in the event of a public health emergency. ^{Reference Balajee, Pasi and Etoundi21,Reference Brooks, Pinto and Gill26,Reference Olu, Lamunu and Chimbaru28,Reference Okeibunor, Nsubuga and Salla56}

Enablers

Conversely, building and sustaining a competent workforce through recruitment, training, and retention of qualified and skilled staff enabled the successful running of a PHEOC. Six studies mentioned the importance of training PHEOC staff in the “practical elements of working in a PHEOC,” including the principles of incident management system, writing action plans, conflict resolution, communication, and logistics management. Along with these, upskilling staff in the technical aspects of a public health emergency such as epidemiology, including analyzing, interpreting, and presenting data, was also important. ^{Reference Bousso19,20,Reference Olu, Lamunu and Chimbaru28,Reference Ding, Li and Jin43,Reference Su, Wu and Lee45,53} One study suggested on-the-job training for coordination leaders to ensure a “better understanding of the coordination mechanism and enhance their coordination capacity” during a public health emergency. ^{Reference Olu, Lamunu and Chimbaru28} Previous experience working in public health emergency response was suggested to enhance efficiency in responding to new public health emergencies. ³⁹

Barriers

Several barriers related to the physical layout and the infrastructure within a PHEOC were found to hinder effective PHEOC operations. These barriers included the PHEOC having inadequate or inappropriate office space, lack of access to the Internet, and lack of access to proper communication equipment. ^{Reference Brooks, Pinto and Gill26,Reference Olu, Lamunu and Chimbaru28}

Enablers

Conversely, the location and design of the PHEOC were found to help promote smooth PHEOC operations. Locating the PHEOC close to or within the ministry of health was deemed important for ease of operations, particularly for staff working dual roles. Using an “open plan” and ensuring space for multidisciplinary teams to meet and share information were found to enhance communication and coordination. In addition, ideally, locating the PHEOC away from potential hazards and having power backup (eg, generator) and paper copies of key documents were suggested to assist continuity of operations in the event of a natural disaster or power failure. ^{Reference Elachola, Al-Tawfiq and Turkestani52} Ultimately, having a permanent PHEOC that can be used during outbreak and non-outbreak periods for routine duties, such as surveillance, was suggested to help sustain resources, infrastructure, and the workforce required to analyze and interpret incoming health information and to assist with a quick transition to response mode in the event of a public health emergency. ^{Reference Ding, Li and Jin43}