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of its neighbours (33); and recent improvements in India’s health system helped that country identify and contain the deadly Nipah virus diagnosed in Kerala in May 2018. Too many places lack even the most rudimentary health-care infrastructure. Communities that cannot care for a pregnant woman and her newborn child cannot protect against a disease outbreak. In the ongoing Ebola response, and for Zika, influenza and other outbreaks in many countries, the national and international leads have been identified after the fact, or changed in mid-course, causing delays in decision-making. Leadership should be clearly identified in advance, authorized and held accountable for preparedness. Although the IHR (2005) requirements are instrumental, they need to be expanded to sectors beyond health to create a broad continuum of preparedness. As a case in point, only four of the 197 national focal points are located outside the country’s Ministry of Health. As potential models, a number of countries have national multisectoral coordination entities to deal with natural disasters, as well as those created to fight against HIV/AIDS. Efforts on national and local preparedness planning too often lack an effective “whole-of-government” and “whole-of-society” approach. Other parties that must be engaged include national agencies beyond the health ministry, local governments, traditional and religious leaders, civil society, the research and security communities, the private sector, the media and operational experts. Preparedness-specific and preparedness-sensitive activities need to be included in sector specific strategies and systems-strengthening plans, such as those for universal health coverage; animal health in agriculture and livestock; transport and security; and disaster risk management. Repeat assessments to monitor progress for JEEs are not yet in place. IHR (2005) SPAR reporting is done by self-reporting in countries. Additional assessment tools are needed to allow identification of weaknesses in preparedness before a health emergency occurs. Community engagement across all aspects of national preparedness planning and response is fundamentally lacking. It is essential to understand community needs and ensure their systematic incorporation into planning and accountability mechanisms. Currently, these needs are not well assessed nor integrated into country and WHO preparedness approaches. Sustainable preparedness requires involvement of women and youth in planning and decision-making. The majority of both formal and informal care givers are women, and their engagement ensures that policies and interventions are accepted and that they have full access to the services provided. It is important to ensure that the basic health needs of women and girls, including those for reproductive health, are met during an outbreak. Persistent challenges and obstacles Poor integration between preparedness and day to day health needs Country coordinating mechanisms for health emergency preparedness are not broad enough A clear national leader for pandemic preparedness and response is too often identified only after the onset of a crisis Whole-of-government and whole-of-society system planning and engagement for preparedness are frequently lacking Monitoring is incomplete and infrequent Grossly insufficient involvement of communities in all aspects of preparedness Inadequate inclusion of women and youth PROGRESS, CHALLENGES, ACTIONS: BUILDING EFFECTIVE SYSTEMS 14 Challenges to poliomyelitis (polio) eradication efforts in Afghanistan and Pakistan and those experienced while containing the tenth Ebola outbreak in the DRC vividly demonstrate the impact that a breakdown in citizens’ trust and social cohesion can have on health emergency response. Consequences include attacks on both national and international health-care workers and delays or stoppages in response efforts. In some countries, waning trust in public health and government officials together with cultural and religious beliefs lead to is decreasing vaccination rates and leading to the re-emergence of measles and other vaccine-preventable diseases, a phenomenon found in communities at all economic and