Off-the-shelf exercise handbook

Health systems resilience exercises

WHO/UHL/IHS/2021.01

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Contents Acknowledgements ........................................................................................................................................... iv

1. Health systems resilience overview ............................................................................................................ 1

1.2 Resilience attributes in the health systems building blocks ........................................................................ 3

2. Exercise preparation ................................................................................................................................... 5

2.1 Overview of off-the-shelf exercises ................................................................................................................ 5

2.2 How to use this handbook and conduct the exercise .................................................................................. 5

2.3 Pre-exercise preparation .................................................................................................................................. 5

2.4 Exercise format ................................................................................................................................................. 5

2.5 Scope and definition of “local” and “national” ............................................................................................. 6

2.6 Exercise purpose and objectives ..................................................................................................................... 6

2.6.1 Purpose .......................................................................................................................................................... 6

2.6.2 Objectives ...................................................................................................................................................... 6

2.7 Timetable ........................................................................................................................................................... 7

2.8 Suggested participants ..................................................................................................................................... 7

2.9 Exercise scenarios and injects ......................................................................................................................... 9

2.10 Scenario and inject preparation .................................................................................................................... 10

2.11 Specific exercise instructions ........................................................................................................................ 10

3. Exercise logistics and delivery .................................................................................................................. 12

3.1 Exercise logistics ............................................................................................................................................. 12

3.2 Exercise delivery ............................................................................................................................................. 12

3.3 Role of the facilitator ...................................................................................................................................... 13

3.4 Exercise debrief ............................................................................................................................................... 13

3.5 Closing the exercise ........................................................................................................................................ 14

3.6 Reporting on the exercise .............................................................................................................................. 14

4. Glossary ..................................................................................................................................................... 16

Additional resources ........................................................................................................................................ 17

References ......................................................................................................................................................... 18

Annex 1. Roles and responsibilities of suggested participants ...................................................................... 19

Annex 2. Templates .......................................................................................................................................... 21

Annex 3. Action plan ........................................................................................................................................ 22

Annex 4. Checklist ............................................................................................................................................ 23

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Acknowledgements This simulation exercise package was developed by Gillian Dacey, Zandile Zibwowa, Frederik Copper, Redda Seifeldin, Andrew Black, Yu Zhang and Geraldine McDarby, under the overall supervision of Sohel Saikat.

Appreciation goes to colleagues at WHO headquarters, the WHO Regional Office for Africa and the WHO Country Office in Zimbabwe: Ed Kelley, Prosper Tumusiime, Stella Chungong, Alex Gasasira, Shams Syed, Raj Sreedharan, Ali Yahaya, Ambrose Talisuna, Mary Stephens, Dirk Horemans, Jennifer Nyoni, Tarcisse Elongo, Juliet Nabyonga, Gertrude Avortri, Mekdim Ayana, Pierre Kariyo, Nonso Ejiofor, Louis Ako-Egbe, Faiqa Ebrahim, Moses Bolongei, Abiy Girmay and Haroon Khan.

Special thanks to WHO partners: Public Health England (Dr Neil Squires, Charles Turner, Paul Sutton and Dr Elena Skryabina), Department of Health, United Kingdom of Great Britain and Northern Ireland (Helen Tomkys) and the United Kingdom Foreign, Commonwealth and Development Office (Martin McKenna, Sam Beckwith, Meredith Bradbury, and Lisha Lala) for their support in the development of the package.

Appreciation also goes to local and national authorities from the nine countries as well as the respective WHO country office colleagues (from Cote d’ Ivoire, Ethiopia, Ghana, Kenya, Liberia, Nigeria, South Sudan, United Republic of Tanzania and Zimbabwe) who participated in the review and pilot workshop held in Harare, Zimbabwe on 19–21 November 2019. Special thanks go to Martin McKenna and Sam Beckwith for representing the United Kingdom Foreign, Commonwealth and Development Office at the workshop, along with Charles Turner of Public Health England. We also appreciate the participation of Rhea Bright from the United States Agency for International Development office in Washington, D.C.

This work was undertaken in the context of the Tackling Deadly Diseases in Africa Programme, funded by the United Kingdom Foreign, Commonwealth and Development Office, which seeks to strengthen collaboration between the health system and health security clusters to promote health security and build resilient health systems.

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1. Health systems resilience overview

1.1 Introduction In the context of emergencies, ‘resilient health systems’ refer to the capacity to provide an effective health response to a public health emergency (PHE) while also maintaining core health services.

This resilience relates to the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganise if conditions require it (1). Functionality of a resilient health system can be based on its ability to provide:

• quality routine health services at all contexts (typical day to day routine care, including

immunisation) • emergency-specific healthcare (when the population suffers from an unanticipated outbreak or

emergencies such as Ebola, MERS CoV, injuries, mass-casualty) • a response to emergencies with public health authorities in the country (e.g. outbreak

investigation, disease diagnosis between clinical and public health laboratories, patient safety and community protection with infection prevention and control, surge capacity to maintain essential health care)

• services to individuals and populations with changing epidemiology (e.g. non-communicable diseases, ageing)

Achieving universal health coverage by 2030 is an important objective of the United Nations Sustainable Development Goals for all countries, and health systems strengthening contributes to this objective (Fig. 1). One way that it does this is by promoting global public health security and increasing the resilience of health systems to respond to health threats that spread both within and across national borders. This requires systematic and targeted consideration of emergency preparedness in all six building blocks of health systems. Service delivery demonstrates functionality and a systems approach in the provision of high-quality health services (Fig. 2).

In an emergency, examples of system aspects could include: activation of an established connection between health care facilities and public health authorities; timely surveillance and contact-tracing involving clinical laboratories, public health laboratories, emergency operations centres, national disease surveillance, rapid response teams and health management teams; provision of a service continuity plan covering mutual aid; surge capacity to access additional resources, medicines and supplies; and clear roles and responsibilities, planned delegation and contact details of all those who need to communicate in a fast evolving emergency situation while avoiding lengthy bureaucratic procedures.

Simulation exercises are a component of the revised International Health Regulations (2005) monitoring and evaluation framework, and are also used extensively in defence, health security and emergency response. Within the context of health systems reviews, simulation exercises are used for:

• ascertaining current capacity to maintain the health services during emergency response;

• developing and testing plans;

• giving responsible authorities the opportunity to practise the delivery of these plans in a simulated environment.

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Fig. 1. Health system strengthening – universal health coverage and the Sustainable Development Goals

Source: WHO Health Services Resilience Team, adapted from (4).

Fig. 2. Health systems framework showing preparedness and high-quality health services as underpinning requirements for resilience

Source: WHO Health Services Resilience Team.

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Simulation exercises can be used to test health system functionality and interconnectedness between different health systems building blocks, making them suitable for supporting health systems strengthening as well as for developing preparedness, response and recovery capabilities.

Currently available simulation exercise materials lack an integrated health systems perspective and have a limited focus on the quality of services delivered in response to a public health emergency (2). Such materials should also focus on the ability of systems to maintain core services effectively during a response (2). The present handbook of off-the-shelf exercises (OTSE) focuses on health services resilience in an emergency environment. It provides a ready-prepared tabletop exercise for health systems personnel to conduct simulation exercises. This OTSE package complements the existing WHO simulation exercise manual (3), which describes other forms of exercise (including tabletop exercises) in detail. Without explicit references, this package also looks at the functionality of and interconnectedness between the six building blocks of health systems as required in an emergency response:

• service delivery

• health workforce

• health information systems

• access to medicines and technology

• financing and

• leadership and governance.

The package includes a list of roles and responsibilities for the suggested participants (Annex 1), templates for required documents (Annex 2), an action plan for the exercise (Annex 3) and a checklist of preparations (Annex 4).

To ensure a coordinated and effective response, these different aspects of the health system not only need to work together, but must also be coordinated with other agencies, such as law enforcement, animal health, port health, environmental health and communities.

1.2 Resilience attributes in the health systems building blocks

The functions of a resilient health system are shown in Table 1 (2). The present series of short simulation exercises focuses on resilience in the six health systems building blocks, which are considered pertinent for maintaining high-quality health services alongside the health systems contribution to an emergency response. However, as this package is a series of short exercises, not all aspects of resilience in the building blocks can be covered in detail.

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Table 1. WHO health systems building blocks – components and resilience attributes

Source: adapted from (2).

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2. Exercise preparation 2.1 Overview of off-the-shelf exercises

An off-the-shelf exercise (OTSE) is a generic tabletop exercise in a simple format that can be delivered to assist agencies with health system strengthening to enhance health services resilience as part of emergency preparedness. It is designed to be developed and delivered by one or two people to a small group at low cost to organizations. All the materials needed to run the exercise are included in this package.

This OTSE has been developed to provide a safe learning environment for governments and health organizations in preparing, reviewing and rehearsing plans and policies to mitigate the effects of future health emergencies. The exercises depict a simulated emergency situation as the basis for a detailed discussion.

During the exercises, no real actions are carried out. The participants (with reference to their usual function) explain and discuss among themselves how they would react to the scenario, without being required to execute those actions. Prior to starting the exercise, it is desirable that all participants have a basic knowledge of any relevant organizational plans, policies or procedures that are in use.

This OTSE package consists of two separate exercises (with different scenarios) – avian influenza and a mass casualty event; each exercise has a local and a national version. The exercises are divided into three work sessions. For each session, there is a series of specific injects and questions to guide the discussion process. The simulation, scenarios and injects are designed to be adapted by users to provide a realistic context for their own country or organization.

2.2 How to use this handbook and conduct the exercise

This handbook contains all the information you need to run this OTSE exercise. It is best used in conjunction with the accompanying slide set, scenario materials and injects. Take particular note of the instructions contained in section 2.9. There is also a checklist for exercise preparation and delivery (Annex 4) that will help to ensure that you cover all the necessary elements of planning.

The slides are designed to take you through delivering the exercise, from the welcome and introduction, through the exercise briefing, work sessions and tasks, to the final debrief and closure. The information on the slides is supported by this handbook.

The handbook is designed for use with this exercise only. For further detailed guidance on conducting exercises generally, please refer to the WHO simulation exercise manual (3).

2.3 Pre-exercise preparation

When you are deciding whether to undertake this OTSE, it is important to consider whether facilitators and participants are adequately prepared to attend such an event. Ideally, before an exercise is delivered, essential planning tasks should be completed, e.g. relevant organizational plans and policies should be in place and relevant staff should be trained in their use. Participants are encouraged to undertake the WHO online simulation exercise training, available free at: https://extranet.who.int/sph/simulation-exercise#parallax-resources.

2.4 Exercise format

This package includes two separate exercises – an outbreak of avian influenza and a mass casualty incident involving toxic industrial chemicals. Each exercise is in a tabletop format with three work sessions, each focusing on a different component of the health system response to the emergency. You should select the version of the

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exercise that most closely fits the health sector tier or component you wish to work on – either local or national (see explanation in section 2.5).

The scenarios develop over the three sessions. Each session has a series of tasks that enable examination of relevant components of interconnectedness between the six health systems building blocks and their functionality, in order to provide high-quality services for individuals and communities affected in relation to the exercise objectives. Video clips are included in the exercise, and tasks for participants accompany each session.

2.5 Scope and definition of “local” and “national”

Each scenario (an outbreak of avian influenza or a mass casualty incident involving toxic industrial chemicals) splits into two levels (local and national) to give authorities two dedicated versions to test health service resilience in different administrative contexts. The overall generic purpose and objectives of the local and national versions are the same. The package has been formulated in a way that is intended to provide authorities with the flexibility to use one scenario – local or national – independently of the other. The definitions of local and national used in relation to these exercises are as follows.

Local: this covers health care facilities at the district level, both remote and in a town or city. Generally, the scope, severity or geographical extent of the incident means that it can be managed at a local level with local resources. However, all incidents have an element of local response, no matter how large or complex they become, and in some cases referral to national health organizations may be required if local services become overwhelmed, or if there is a requirement for specialist services or assets that can be made available only through national authorities (for example, medical rapid response teams or chemicals information).

National: this covers health organizations with a national responsibility (including the ministry of health, national public health institutes, national laboratories, WHO country office and other government departments and agencies) and specialized assets such as rapid response teams and toxicologists. Generally, national-level organizations become involved because the scope, sensitive political/economic location, severity or geographical extent of the incident are beyond the capacity of local organizations. Incidents that may require a national-level response include those affecting national infrastructure or resources, a large-scale and/or highly contagious disease outbreak, or incidents that result in large numbers of casualties that overwhelm local health facilities.

If you wish to include subnational or regional-level participants or organizations as part of the exercise, you will need to adjust the participant list accordingly (see section 2.8).

2.6 Exercise purpose and objectives

2.6.1 Purpose

To develop, review, test and practise the knowledge and capacity of health authorities and health workers in order to strengthen their capacity to prepare for and respond to disruptive health emergencies, with a focus on health service resilience.

2.6.2 Objectives

1. To review, test and practise the functionality of relevant health systems at the policy and operational levels before, during and after public health emergencies.

2. To explore the linkage and coordination between health care facilities and public health authorities when disruptive emergencies occur that have an impact on health systems.

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3. To examine the ways in which considerations for health service preparedness are maintained and embedded within the building blocks of health systems and national response frameworks and the way these operate during an emergency.

2.7 Timetable

A suggested timetable for the exercise involves approximately four hours of contact time, excluding breaks (Table 2).

Table 2. Timetable for the exercise

Time (indicative) Activity 09:00 Welcome (10 mins) 09:10 Introductions and scene-setting (10 mins) 09:20 Exercise briefing (10 mins) 09:30 Session 1 (60 mins) 10:15 Feedback (15 mins) 10:30 Coffee break (30 mins) 11:00 Session 2 (60 mins) 11:45 Feedback (15 mins) 12:00 Session 3 (60 mins) 12:45 Feedback (15 mins) 13:00 Lunch (60 mins) 14:00 Exercise debrief (90 mins) 15:15 Exercise feedback and next steps (15 mins) 15:30 Close

You can adapt the suggested timetable to allow more or less time in each session in order to facilitate sufficient discussion in a no-stress environment. You can also be selective in adding questions or injects, depending on the attendees and your objectives. Keep an eye on time in each session so that you allow enough time for all three sessions of the exercise. If you are running behind, consider changing the coffee breaks, or turn them into “working” breaks so that participants can catch up.

2.8 Suggested participants

Ensuring an appropriate mix of attendees will help to ensure that the exercise objectives are met. To achieve most from the exercises, it is helpful if participants attend from a variety of backgrounds. Depending on the level of the health sector that you are running the exercise for, you should try to have at least one representative of each of the groups listed below (Tables 3 and 4). Attendance by senior staff members with knowledge of the plans at a strategic level and managerial responsibility to implement recommendations is also important when conducting tabletop exercises.

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Table 3. Suggested participants for avian influenza exercise

Local National

• Facility responsible officer/manager • Officer in charge of the emergency

department • Officer in charge of finance • Officer in charge of human resources • Officer in charge of communications • Officer in charge of emergency

operations centre • Local public health official

(emergencies) • Officer in charge of pharmacy and/or

laboratory services • Local epidemiologist • Local health

information/surveillance officer • Technical adviser – influenza • Technical adviser – animal health • Head of district health management

team • Officer in charge of logistics • School health services • Community health officer

• Hospital chief executive officer • Director – national public health

institute • Director – health • Ministry of health – emergency

preparedness manager • Ministry of health – national health

finance officer • Ministry of health – health staff

manager • Ministry of health – health

communications manager • National health emergency

operations centre manager • Ministry of health – public health

official (emergencies) • National laboratory

officer/manager • National epidemiologist • National health

information/surveillance manager • Technical adviser – influenza • Technical adviser – animal health • Officer in charge of logistics

These are sample lists; you may want to include other relevant health representatives, depending on your health system structure. We give generic participant titles here, which may not exactly match those used in your country or health system; therefore, you will need to adapt accordingly. A brief definition of the roles and responsibilities of these positions is included in Annex 1. Note that some aspects of these exercises would normally require a multisectoral or multiagency response; however, not all agencies need to be physically present in the exercise room.

Try to limit the number of participants to no more than 15, as this group size is easier to manage. Ideally, participants should be the people who would be expected to manage (coordinate) a real-life response, making the exercise more realistic. Duplication of roles, attendance of observers and non-participation by critical staff can make the exercise more difficult to manage and distract the participants. One observer may be invited to attend the session and provide feedback to the facilitator and participants.

Relationship-building is a key component of successful preparedness and response. Do not assume that all participants know each other, and make sure people introduce themselves. It is also important to stress that the exercise is not intended to evaluate the performance of individuals or facilities, but provides an opportunity to discuss frankly and identify the strengths and weaknesses in the system and jointly develop feasible action plans to strengthen the capacity of the system to respond to public health events in the future. It is highly

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recommended that you offer lunch and refreshments to ensure that people stay until the end and to encourage informal networking during and after the exercise.

Table 4. Suggested participants for mass casualty exercise

Local National • Facility responsible officer/manager • Officer in charge of the emergency

department • Officer in charge of finance • Officer in charge of human resources • Officer in charge of communications • Officer in charge of the emergency

operations centre • Officer in charge of ambulance services • Technical adviser – chemicals/poisons • Officer in charge of pharmacy and/or

laboratory services • Officer in charge of waste management • Officer in charge of logistics • Head of district health management team • School health services • Community health officer

• Head of district health management team

• Director – national public health institute

• Director – health • Ministry of health – emergency

preparedness manager • Ministry of health– finance manager • Ministry of health – health staff

manager • Ministry of health – health

communications manager • National health emergency operations

centre manager • Officer in charge of ambulance

services • National technical adviser –

chemicals/poisons of the ministry of environment (or equivalent)

• Officer from port health authority • Officer in charge of logistics

2.9 Exercise scenarios and injects

This OTSE package contains two separate exercises with different scenarios, which are intended to be run independently. The scenarios focus on an infectious disease outbreak and a mass casualty incident, both of which could reasonably be expected to occur in most countries. The two different scenarios allow for a dedicated focus on different administrative tiers or parts of the health systems. The scenario of an avian influenza outbreak is slow in onset, while the mass casualty incident scenario is sudden in onset, calling for different ways of preparing and responding.

The scenario themes (avian influenza variant and a mass casualty incident involving toxic chemicals) can be adapted to fit your own country, health system and location. The infectious disease scenario is divided into different time periods that reflect the activities necessary following the onset of an outbreak of influenza.

Injects are scripted pieces of information inserted into an exercise at intervals and aimed at one or more participants. They are designed to elicit a specific response and facilitate the flow of the exercise. Injects can be written, oral, televised or transmitted via other means (e.g. presentation slides, fax, phone, email, voice, radio or sign) by one of the exercise manager/facilitators (3).

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2.10 Scenario and inject preparation

There are two slide sets for each exercise scenario, one for use at national level and the other for the local level. Each slide set contains the relevant part of the scenario, along with a selection of tasks to be completed during the session.

The tasks are in the form of questions for the participants to discuss. Please note that they are indicative questions, with the purpose of facilitating the discussion and getting participants to summarize information in a concise manner. It will not be possible to complete all the tasks for each session in the 45-minute time frame. Therefore, before running the exercise, you should edit the slides by prioritizing the tasks which help participants to examine the functionality of the block(s) of health systems you intend to test and removing other tasks. The aim of these tasks is to trigger discussion.

Appropriate tasks should be chosen from those provided in order to meet the exercise objectives in the context of the health system and participants involved. The tasks should be selected prior to the exercise and will ideally involve consultation with those commissioning the exercise. You will need to adapt the presentation slides accordingly.

2.11 Specific exercise instructions

There are local and national versions of the exercises, and the scenarios differ slightly in each. All the exercises have three sessions. Each session begins with the exercise manager giving the participants the appropriate scenario information and then facilitating the participants’ discussion of the relevant tasks.

The materials to be given to participants in each exercise are as follows.

Avian influenza scenario – local • Session 1 – hand out printed copies of session 1 scenario information. • Session 2 – hand out printed copies of session 2 scenario information and the A(H7N11)

factsheet. Show the video. • Session 3 – hand out printed copies of session 3 scenario information and the social media

page. Avian influenza scenario – national

• Session 1 – hand out printed copies of session 1 scenario information and the A(H7N11) factsheet. Show the video.

• Session 2 – hand out printed copies of session 2 scenario information and the social media page.

• Session 3 – hand out printed copies of session 3 scenario information.

Mass casualty scenario – local • Session 1 – hand out printed copies of session 1 scenario information and the chlorine

factsheet. Show video 1. • Session 2 – hand out printed copies of session 2 scenario information. Show video 2. • Session 3 – hand out printed copies of session 3 scenario information and the social media

page.

Mass casualty scenario – national • Session 1 – hand out printed copies of session 1 scenario information and the chlorine

factsheet. Show video 1. • Session 2 – hand out printed copies of session 2 scenario information. Show video 2.

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• Session 3 – hand out printed copies of session 3 scenario information and the social media page.

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3. Exercise logistics and delivery 3.1 Exercise logistics

Planning for the exercise should start at least two months beforehand; this is to ensure that invitations are sent out in time and that the venue and other logistical issues can be organized.

Participants should be sent the information about the exercise well in advance. They will need an invitation letter that contains the necessary joining instructions, e.g. location, date and time, as well as any reference material or plans they may need to bring, or read beforehand. The simulation exercise package includes a template invitation letter (Annex 2). You may consider including some general information about tabletop exercises and how they work, particularly if participants are unfamiliar with the concept of simulation exercises. The generic exercise materials available from WHO are listed in Annex 2 as additional resources.

If you are to run the exercise successfully, a number of logistics activities and resources should be completed prior to the event taking place. Annex 2 of this handbook contains some template documents you may find useful when organizing and running the exercise.

At the venue you will need the following:

• projector, screen and laptop/computer with video capability – to deliver the exercise briefing, scenario and tasks;

• flipchart, paper and marker pens – to record groupwork discussions;

• name badges for participants;

• a room with a suitable layout – the most effective layout is horseshoe or boardroom style, which enables discussions and small-group work, as well as allowing for feedback; depending on numbers, you may choose to split the group into two;

• a space for refreshments during and after the exercise.

It is necessary to set up the room in a way that encourages discussion. Ideally the venue should be the emergency operations centre or its equivalent, a conference room, boardroom or other appropriate meeting venue. Alternatively, an off-site location may avoid the problem of people being interrupted by other demands if they remain in their normal workplace.

3.2 Exercise delivery

As the exercise manager (person delivering the exercise), you have several key actions to perform in order to deliver the exercise successfully. Many of these actions are already outlined in the OTSE slide presentation:

• welcome participants and give the general administrative introduction;

• remind the participants that this is a safe learning environment;

• emphasize the fact that this is an exercise and all material used or seen should remain in the room, to avoid rumours of an outbreak spreading in the community;

• deliver the exercise briefing;

• start the exercise with the scenario and first set of tasks;

• ensure good timekeeping and manage group discussions in the room;

• facilitate the feedback sessions (if no separate facilitator is present);

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• conduct the debrief;

• produce the exercise report (unless this task is allocated to another person) specifying areas of good practice and improvements, and identifying authorities responsible for improvements;

• provide a debriefing of the exercise and its findings for senior leadership to obtain their support to implement the recommendations.

There are no role-plays in this exercise; all participants are required to be themselves, with their role based directly on the functions they are responsible for in their organization. They should respond as they would if this were a real emergency.

Every participant has a vital role to play in identifying challenges and strengths within the system, in particular as it relates to their own roles and functional areas. Participants must therefore feel safe and be encouraged to highlight any strengths, gaps or opportunities and make recommendations on ways that the system can be improved.

3.3 Role of the facilitator1

Depending on the number of people running the exercise, the facilitator may be a different person to the one who is delivering the exercise. One facilitator for 15 people is adequate.

In addition to ensuring the smooth running of the exercise and debriefing, the task of the facilitator is to assist the participants in achieving the stated objectives of the simulation. The facilitator should not provide direct answers to questions raised or identified by the participants, but should instead encourage discussion by all participants while, at the same time, maintaining the overall flow of the exercise.

Facilitating the exercise involves leading the participants through the sessions and associated tasks and ensuring that the discussion remains focused on the tasks and overall exercise objectives. To help facilitators with this series of exercises, the task slides in the exercise presentation have facilitator notes attached. Ensure that participants write down their responses to the tasks, as these may be needed to inform the final report.

To facilitate an exercise well, you need good communication and listening skills and the ability to empower participants to work as a group to achieve their aims. During discussions, you may need to engage quiet participants, restrain strong speakers and ensure that everyone has a chance to play an active role in the exercise. You should not take charge of the discussion, but let the participants discuss the relevant issues and keep them within the boundaries of the exercise objectives.

During the feedback plenary at the end of each session, you will need to coordinate the feedback from participants. Ask participants to feed back their responses to the tasks, including whether there were any challenges or gaps in their responses. Try and get a summary, not a long-winded replay of the discussion. Encourage quieter people to contribute as well. During feedback, make sure the comments are documented, as these will contribute to the overall exercise report.

3.4 Exercise debrief

The exercise manager is responsible for leading the exercise debrief.

1 The facilitator should be an experienced public health professional with solid understanding of health systems resilience and service delivery in the context of emergencies. She or he should be well respected by peers, with a track record of managing complex discussion and distilling diverse views into coherent recommendations. However, the facilitator does not have to be a person in a position of authority in the health system. Ideally, the facilitator should be someone with whom the participants do not feel intimidated or reluctant to speak openly (e.g. a technical officer who is not in a position of authority in the health system structure, or an academic). It is the role of a good facilitator to create the right environment for participants to reflect and contribute freely and candidly.

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The aim of the exercise debrief is to assess the current response arrangements as they were discussed during the exercise. The debrief will help to identify areas where these arrangements are working well and where they are unclear, or not working so well, and need to be reviewed.

It is important to hold an exercise debriefing with participants immediately after the exercise. The debrief should be guided by the exercise objectives. Ask the participants to consider the following aspects for each objective:

• what went well?

• what went less well?

• what are the areas for improvement?

Once participants have had time to consider the key points, ask each one to feed back their views.

You will need to manage the conversation to ensure that participants discuss the health systems resilience and response arrangements and not the detail of the exercise itself (they will have the opportunity to feed back on the exercise later). Ensure that the conversation keeps to the required objectives of the exercise and avoid distracting topics that can be discussed later, outside the exercise. Capture the information from the debriefing session, as this will form the basis of the exercise report.

You should:

• summarize the challenges and recommendations identified by the participants;

• clarify any outstanding points and record concrete recommendations, solutions or agreements on the way forward.

3.5 Closing the exercise

At the end of the debriefing process, you will need to close the exercise. At this point, you should thank participants for their input during the exercise, and explain the next steps to them, with clear agreed timelines. This should include information about the evaluation and reporting process (see below).

Finally, general participant feedback or evaluations of the exercise should also be collected, as this will help to develop the exercise and the way it is run. The participant feedback template form included with the OTSE package (see Annex 2) can be used for this purpose and contains some sample questions. The form should not take more than three minutes to complete at the end of the exercise. It is important you collect the responses and feed these back to WHO to enable further improvements to be made to the OTSE programme. Where resources (e.g. internet connection) are available, an anonymous interactive electronic platform (e.g. Mentimeter, www.menti.com) can be set up for participants to evaluate the tabletop simulated exercise.

3.6 Reporting on the exercise

The final activity is to compile the exercise report. Before the exercise, you should have identified the person who will write the report. It may be yourself, or another nominated person who has the authority and relevant experience to do this. The facilitator may appoint someone to record important discussion points which will feed into the overall exercise report.

The exercise report should include a summary of the lessons identified during the debriefing process, and reports from any observers and other facilitators. Lessons only become learned when they are incorporated into organizational plans.

One of your most important actions is to ensure that the report highlights any lessons identified and encourage senior managers to act on recommendations from the exercise. There may be specific recommendations for

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authorities responsible for health service delivery and the health systems building blocks in general, as well as authorities responsible for emergency preparedness and response, animal health, utilities and the environment.

Ideally, once the draft report has been written, you should report back to senior management and share initial findings, including any challenges, achievements and recommendations. Support from senior management may be required to enable the recommendations to be implemented.

The final version of the report should be endorsed by senior management and any key stakeholders to ensure implementation of any recommendations or action plan. A sample action plan is shown in Annex 3.

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4. Glossary Below is a list of some of the terms and definitions used in this handbook. For further information on simulation exercises, refer to the WHO simulation exercise manual.

• Debrief – the process immediately following the exercise, involving participants and the exercise management team. Individuals share their perspectives on strengths, weaknesses and areas for improvement. Outputs from the debrief process inform the exercise report.

• Inject – a piece of information inserted into the exercise that requires a specific response from participants, and can also drive the scenario forwards. Injects may be written, oral or transmitted by other means by an exercise controller (3). In this OTSE, injects are supplemented by tasks (see below).

• Off-the-shelf exercise (OTSE) – a generic tabletop exercise that is simple in format and designed to be developed and delivered by one or two people at low cost.

• Resilient health systems – a system that can provide an effective health response to a public health emergency, while also maintaining core health services.

• Scenario – a pre-scripted fictitious, but plausible, story designed to ensure that the objectives of the exercise are met. Often based on a reasonable worst-case situation that could occur in real life.

• Simulation exercise – a form of practice, training, monitoring or evaluation of capabilities, involving the simulation of an emergency situation to which a described or simulated response is made.

• Tabletop exercise – a simulated exercise where participants are involved in a facilitated discussion of an emergency situation, generally in an informal, low-stress environment.

• Task – a question or series of related questions that require discussion by participants; like an inject, the task can also drive a scenario forwards.

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Additional resources Global mapping of simulation exercise materials: a health system view. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/bitstream/handle/10665/311137/9789241515399-eng.pdf, accessed 3 July 2021). Licence: CCBY-NC-SA3.0IGO.

SimEx toolbox. In: Simulation exercises [website]. Geneva: World Health Organization; 2021 (https://www.who.int/emergencies/operations/simulation-exercises, accessed 3 July 2021).

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References 1. Kruk ME, Myers M, Varpilah ST, Dahn BT. What is a resilient health system? Lessons from Ebola.

Lancet. 2015;385(9980):1910–12. doi:https://doi.org/10.1016/S0140-6736(15)60755-3.

2. McDarby G, Reynolds L, Zibwowa Z, Syed S, Kelley E, Saikat S. The global pool of simulation exercise materials in health emergency preparedness and response: a scoping review with a health system perspective. BMJ Global Health. 2019;4:e001687. doi:10.1136/bmjgh-2019-001687.

3. WHO simulation exercise manual: a practical guide and tool for planning, conducting and evaluating simulation exercises for outbreaks and public health emergency preparedness and response. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/handle/10665/254741. License: CC BY-NC-SA 3.0 IGO, accessed 3 July 2021).

4. Leave no one behind: strengthening health systems for UHC and the SDGs in Africa. Brazzaville: WHO Regional Oce for Africa; 2017 (https://www.afro.who.int/sites/default/files/2017-12/UHC%20framework_eng_2017-11-27_small.pdf. Licence: CC BY-NC-SA 3.0 IGO, accessed 6 July 2021).

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Annex 1. Roles and responsibilities of suggested participants Ambulance service senior manager (local or national) A person within the ambulance service who holds a senior operational management role and

a liaison role with other organizations

Communications manager (hospital or ministry of health ) A person with the responsibility of communicating organizational messages to the media and

the public

Director of national public health institute A person who holds a senior executive position within the national public health institute and

who liaises with the ministry of health

Director – health A person who holds a senior executive position within the ministry of health and who liaises

with the Minister of Health

Emergency operations centre manager (hospital or ministry of health) The person who manages the emergency operations centre for the organization during an

emergency (may not be a full-time role)

Epidemiologist (local or national) A person trained as an epidemiologist who works with a public health organization to

understand the cause, patterns and impact of a disease

Finance manager (hospital or ministry of health ) A person in charge of finance within the organization, including budgeting for emergencies

and ensuring legal compliance with financial matters

Head of district health management team A person who leads a local or district (or maybe regional) health management team

Health information/surveillance officer (local or national) A person with specific expertise in the management of health information and/or disease

surveillance, who works with a public health organization

Hospital chief executive officer A person who has overall responsibility for the management and functioning of the hospital

Hospital emergency department senior manager A senior manager within the emergency department of the hospital or emergency receiving

unit of a health clinic; may have a clinical background

Hospital senior managers People who hold senior positions within the hospital, such as clinical, surgical and nursing

department managers

Human resources/staff manager (hospital or ministry of health) A person with responsibility for implementing employee relations and human resources

programmes within the organization

Laboratory officer/manager (local or national)

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A person working in a public health or clinical laboratory, preferably with expertise in influenza and swab sampling or chemical toxicology (depending on scenario)

Ministry of health emergency preparedness manager A person within the ministry of health with responsibility for emergency preparedness

activities for the health sector

Public health official (emergencies) (local or national) A person involved in the management of public health emergencies, including disease

outbreaks

Technical adviser – animal health (local or national) A person with specific expertise in animal (avian) health, who is able to advise the health

sector on interactions between animal and human health

Technical adviser – chemicals/poisons (local or national) A person with specific expertise in chemicals and poisons who is able to advise the health

sector on interactions with human health

Technical adviser – influenza (local or national) A person with specific expertise in influenza, and who is able to advise the health sector on the

impact on human health

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Annex 2. Templates The template documents below are part of the online SimEx toolbox (see Additional resources above) and can be amended for your own use. Other templates are also available online.

Admin and logistics checklist

https://www.who.int/ihr/publications/TTx-06-admin-and-logs-checklist.xlsx?ua=1

Venue checklist and room layout

https://www.who.int/ihr/publications/TTx-19-Venue-Checklist.docx?ua=1

Participant invitation template

https://www.who.int/ihr/publications/TTx-08-participant-invitation-template.docx?ua=1

Participant feedback form template

https://www.who.int/ihr/publications/TTx-15-Participant-Feedback-Form-Template.docx?ua=1

Exercise participation certificate template

https://www.who.int/ihr/publications/TTx-21-participant-certificate-template.pptx?ua=1

Exercise report template

https://www.who.int/ihr/publications/TTx-24-Exercise-Report-Template.docx?ua=1

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Annex 3. Action plan Below is a sample action plan template that can be used in conjunction with the exercise report to list the identified actions, the person to whom the action is allocated, and the dates for start and completion.

No. Action Action

done by Date started

Date completed

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Annex 4. Checklist Below is a sample checklist for preparations to deliver the exercise. You may need to add or remove some of these tasks, depending on your situation.

Logistics checklist – before the exercise

Task Items and remarks

Date Responsibility (person)

Status due

Resources

Facilitation team identified and confirmed

Guidance, tools and templates available

Budget prepared Funding sources agreed Guidance, tools and templates available

Venue

Venue selected (security approved, appropriate size)

Final venue booked Venue setup Supplies and equipment delivered and set up

Catering

Catering package (meals and refreshments)

Catering confirmed and times provided

Invitations

Participants identified Participants invited Participant list created

Facilitator accommodation

and transport

Visa letters sent (if needed)

Airport transfers (if needed) – to and from airport

Accommodation booked Participant

accommodation and transport

Transport booked (if needed) Accommodation booked

Supplies

2 x flipcharts on stands, with paper

Pad of paper and water per person

Rubbish and paper recycling bins

Large clock for the room

Stationery

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Logistics checklist – before the exercise

Task Items and remarks

Date Responsibility (person)

Status due

• Name badge holders • Pens • Flipchart paper and markers

• Adhesive tape (paper tape)

• Scissors • Packet of A4 print paper • Pack of large sticky notes (e.g. Post-it)

Equipment

Microphone and speakers (sound system)

Liquid crystal display (LDC) projector, cables and screen, including high-definition multimedia interface (HDMI) connector

Presentation remote control Facilitator laptops

Print/ documents

Name badges

Registration sheet Print agenda Participant feedback form printed or uploaded into interactive polling software (e.g. Menti)

Scenario documents, factsheets, social media sheets