The Global Health Security Index and Its Role in Shaping National COVID‑19 Response Capacities: A Scoping Review

Introduction

The Global Health Security Index (GHSI) represents a pioneering effort to evaluate and benchmark health security and related capacities across all 195 countries that are States Parties to the International Health Regulations. This comprehensive assessment aims to drive tangible improvements in national health security preparedness while strengthening global readiness to address infectious disease outbreaks. By focusing on measurable enhancements, the GHSI seeks to bolster international capabilities to swiftly detect, respond to, and mitigate the impact of epidemics and pandemics, thereby safeguarding global health and stability in an interconnected world [1].

Shortly after the launch of the GHSI, the coronavirus disease 2019 (COVID‑19) pandemic emerged as an unprecedented global health crisis. Caused by the novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2), COVID‑19 has been described as the most significant health threat of the 21st century. Originating in Wuhan, China, toward the end of 2019, the virus rapidly spread across continents, prompting the World Health Organization to declare it a pandemic in March 2020 [2]. The rapid transmission [3] and severe health consequences [4, 5] underscore the critical importance of robust health security frameworks and preparedness measures, highlighting the urgent need for continuous advancements in global health security strategies to effectively manage future pandemic risks.

The COVID‑19 pandemic has profoundly impacted healthcare systems globally [6–8], reverberating across multiple sectors of the global economy. Frontline healthcare workers have been particularly vulnerable due to their direct exposure to infected patients, placing them at heightened risk of contracting SARS‑CoV‑2. This underscores the necessity of robust infection control measures and adequate personal protective equipment (PPE). Simultaneously, healthcare delivery for the general population has faced significant challenges, exacerbated by surging demand for medical supplies, restrictions on in‑person medical consultations due to infection control protocols, and shortages of essential protective gear. These disruptions have necessitated rapid adaptations in healthcare delivery, emphasizing telemedicine and digital health [9] solutions to maintain continuity of care while minimizing transmission risks. Addressing these complexities requires concerted efforts to strengthen healthcare infrastructure, enhance supply chain resilience, and support frontline healthcare workers in managing ongoing and future health crises [10].

Beyond health consequences, efforts to contain the pandemic led to extensive lockdowns [11] and social distancing [12] measures, which resulted in significant economic losses for individuals, businesses, and governments, with some countries facing the risk of recession [10]. Financial markets have been affected, and disruptions to international supply chains have been widely observed [13].

The COVID‑19 pandemic has served as both a test of health security infrastructures worldwide and a real‑world validation of the Global Health Security Index (GHSI). The exponential rise in infections, mortality rates, and widespread transmission has reinforced findings from the GHSI, revealing that no country was fully prepared for a pandemic of this scale [14, 15]. However, discrepancies have emerged between GHSI scores and the actual responses of some countries, sparking debate and controversy. These inconsistencies highlight the complexities of assessing and predicting pandemic preparedness, emphasizing the need for continuous refinement of global health security frameworks to better mitigate future crises [16].

This scoping review examines the existing scientific literature on the impact of the Global Health Security Index (GHSI) on COVID‑19 responses across different countries. The GHSI, designed to assess national preparedness for health emergencies, became a key metric for evaluating how well countries managed the challenges of the pandemic. By synthesizing findings from various studies, this review explores the correlation between GHSI scores and the effectiveness of pandemic responses while identifying gaps and inconsistencies in global preparedness strategies. The findings provide insights into the strengths and limitations of the GHSI in enhancing global health security and offer recommendations for improving future pandemic preparedness frameworks.

Research Questions

Using the scoping review methodology, this study addresses the following specific research questions:

1. How did a country’s Global Health Security Index (GHSI) score influence its capacity to respond to COVID‑19?

2. To what extent does the GHSI accurately reflect a country’s actual COVID‑19 response capacity, and what lessons can be drawn from this?

Method

This scoping review adhered to the five‑stage framework from Arksey and O’Malley [17] and the Preferred Reporting Items for Systematic Reviews and Meta‑analyses (PRISMA) statement for scoping reviews [18] (Supplementary Table S1).

Data screening and extraction

The screening and extraction process is illustrated in Figure 1. All retrieved search results were exported from electronic databases in Research Information Systems (RIS) format and imported into EndNote 21, where duplicate entries were systematically removed. The remaining studies were then imported into Microsoft Excel 2021 [19] for title and abstract screening. Studies that did not meet the predefined inclusion criteria were excluded.

Figure 1

Full‑text articles were subsequently assessed for eligibility on the basis of the inclusion and exclusion criteria. Studies that lacked relevance to the Global Health Security Index (GHSI) in the context of COVID‑19 or exhibited insufficient methodological rigor were excluded.

The screening process was conducted by three independent researchers. Each researcher reviewed a portion of the retrieved articles during the initial title and abstract screening to ensure consistency and validation. During the full‑text review, all three researchers collaborated to assess eligibility. Any discrepancies in study selection were resolved through discussion, and the finalized studies were included in the data synthesis.

Result

Component of the COVID‑19 parameters

In this analysis, specific COVID‑19 parameters were used to provide a comprehensive overview of each country’s capacity to respond to the pandemic. These parameters are categorized into five main groups, namely detection, mortality, transmission, fatality, and recovery, as illustrated in Figure 2. Each category captures key aspects of the pandemic’s impact and evaluates the effectiveness of public health measures. Detection includes metrics such as the number of confirmed cases, cumulative incidence, and testing rates. Transmission was assessed using the basic reproduction rate (R₀), daily increase rate, and infection rate. Fatality was measured by the case fatality rate (CFR) and lethality rate. Mortality parameters encompassed the total number of deaths, mortality rates, weekly mortality, and excess mortality. Finally, recovery was analyzed using the total recovery rate, vaccination rate, and the number of persons fully vaccinated. These categories together provide a well‑rounded understanding of the pandemic’s dynamics and the effectiveness of interventions across countries.

Figure 2

Impact of a country’s GHSI on its COVID‑19 response capacity

Table 1 and Figure 3 summarize the relationship between GHSI scores and COVID‑19 parameters, as reported in the 20 reviewed studies.

Table 1

Summary of the study impact of GHSI score on COVID‑19 parameters.

COVID‑19 PARAMETER	NUMBER OF STUDIES	NO SIGNIFICANT ASSOCIATION	HIGH GHSI SCORE—HIGH PARAMETER	HIGH GHSI SCORE—LOW PARAMETER
Detection	13	[13, 15, 21–26]	[27, 28]	[29–31]
Transmission	4	[32]	—	[15, 33, 34]
Fatality	5	[29, 32]	[35, 36]	[37]
Mortality	12	[22, 26, 31]	[13, 21, 15, 24, 28, 29, 37]	[34, 37, 38]
Recovery	5	[22, 23, 31]	[28]	[13]

Figure 3

Discussion

Our study revealed significant variation in how the Global Health Security Index (GHSI) score influenced national responses to COVID‑19. While some studies support the GHSI as a valid health security indicator correlated with stronger response capabilities, others found no significant association with actual outcomes, highlighting its limitations in predicting real‑world effectiveness.

Countries with higher Global Health Security Index (GHSI) scores were expected to report fewer confirmed cases, lower transmission and mortality rates, and higher recovery rates owing to enhanced healthcare infrastructure and early detection capabilities. However, pandemic “success” is multifaceted, shaped not only by health outcomes but also by the timing and nature of interventions, complexities that a single metric such as the GHSI cannot fully capture. Additionally, regional variations in mortality data reliability raise concerns about data completeness and comparability. Furthermore, the cross‑sectional design of many studies may limit the ability to assess the long‑term effectiveness of interventions, particularly in the evolving context of COVID‑19 [39].

Several factors should be considered when interpreting the Global Health Security Index (GHSI) as a predictor of pandemic response effectiveness. First, COVID‑19 posed an unprecedented infectious disease challenge, overwhelming the response capacities of many countries [15]. The biological characteristics of SARS‑CoV‑2, such as its ability to spread from asymptomatic individuals [40], combined with increased global connectivity [41], facilitated rapid transmission on an unprecedented scale. These factors highlight the need for preparedness metrics that account for the unique challenges posed by highly transmissible pathogens.

Second, significant disparities in access to COVID‑19 health products [42], particularly between high‑income countries (HICs) and low‑income countries (LICs), have profoundly shaped the pandemic’s trajectory. Limited initial testing capacity [15] and uneven vaccine distribution [43] exacerbated these inequalities, leading to prolonged transmission and higher infection rates in LICs. Beyond widening global health disparities, these inequities also increase the risk of new variants, which can undermine containment efforts worldwide.

Third, while the GHSI is a comprehensive metric, it heavily relies on publicly available data [44], which may overlook unreported yet effective health interventions or fail to capture the true quality of healthcare systems, particularly in lower‑income settings [23]. Fourth, the GHSI does not account for the role of political leadership in pandemic response, despite its significant influence on public health outcomes [44, 45]. The COVID‑19 pandemic underscored how policy decisions, coordination, and leadership shape crisis management [46].

For example, despite the United States’ high GHSI score, the country experienced high COVID‑19 incidence and mortality, partly due to conflicting guidance between President Trump and public health experts [47]. In contrast, South Korea [48] and New Zealand [49] demonstrated notable success through strong leadership, clear communication, and well‑coordinated responses, including the timely deployment of testing and contact tracing, resulting in relatively favorable health outcomes.

Lastly, the reliance on low‑quality data and the potential oversimplification of analyses using the GHSI may lead to misleading interpretations [35, 44]. In some cases, the observed correlation between high GHSI scores and COVID‑19 parameters such as detection, mortality, transmission, fatality, and recovery capacity may not imply a causal relationship. Instead, it may highlight limitations in data quality and the complexities of health system effectiveness. To achieve a more accurate assessment of preparedness and response, future research should incorporate longitudinal study designs and account for more nuanced factors beyond standardized metrics.

The findings from Ledesma et al. [34] suggest that countries with strong preparedness capabilities, such as effective disease prevention, detection, and robust health system infrastructure demonstrated higher data completeness and lower COVID‑19 infection and mortality rates. This supports the idea that well‑prepared nations are better equipped to track and respond to pandemics, leading to more accurate data and more effective public health interventions. Moreover, after accounting for data completeness, a negative correlation emerged between preparedness and disease burden, indicating that countries with better preparedness experienced lower infection and mortality rates.

COVID‑19 has exemplified a catastrophic infectious disease outbreak of unprecedented scale in recent decades, overwhelming the control capacities of many countries [8]. Addressing the inequality in access to health products and technology between high‑income and low‑income countries must be a priority in future pandemic treaties [42]. The significant disparities in access to COVID‑19‑related health products and technologies not only deepen global health inequities but also risk prolonging the pandemic, increasing the likelihood of new variants, and undermining global containment efforts [50].

The uneven distribution of vaccines [43], treatments, and diagnostics [42] has slowed infection rate declines in low‑income countries, increasing the risk of sustained transmission and the emergence of new variants that could jeopardize global containment efforts. Developed nations typically achieve higher GHSI scores due to their greater capacity and resources, whereas lower GHSI scores in developing countries reflect systemic resource limitations. These disparities exacerbate existing social inequalities, further marginalizing vulnerable populations and weakening global solidarity. To address these challenges, future preparedness frameworks should incorporate measures that evaluate equitable access to healthcare resources.

Our study emphasizes that the GHSI did not accurately reflect a country’s capacity to respond to the COVID‑19 pandemic. However, this does not undermine the value of the GHSI, which is intended to identify gaps that countries must address [44]. It remains a valuable tool for identifying essential capacities and capabilities that are necessary, though not sufficient, for an effective pandemic response [39]. Rather, this finding underscores the complex and unpredictable nature of pandemics, which are shaped by factors that extend beyond the current GHSI metrics.

A key recommendation is for the expert panel overseeing the GHSI to regularly reassess its criteria, integrating additional variables such as leadership quality, governance, public health infrastructure, and socio‑cultural factors. These elements have proven essential in shaping effective pandemic responses. Including such factors in the GHSI would enhance its ability to reflect a country’s true preparedness and response capabilities, providing a more comprehensive tool for global health security. By evolving to incorporate a broader range of indicators, the GHSI can better guide countries in strengthening their health security frameworks, ultimately leading to improved outcomes during future public health crises.

Conclusion

Our study emphasizes that the Global Health Security Index (GHSI) does not fully capture a country’s ability to respond effectively to the COVID‑19 pandemic. However, this does not undermine the GHSI’s value. Instead, it highlights the need for its continuous evolution. The GHSI remains a vital tool for identifying critical gaps in the capacities and capabilities required for an effective pandemic response. To improve its accuracy and relevance, the index should incorporate a wider range of variables, such as political leadership, governance, public health infrastructure, and socio‑cultural factors, all of which play pivotal roles in managing public health crises.

Regular reassessment and refinement of the GHSI criteria would not only enhance its predictive power but also support countries in identifying and addressing deficiencies in their health security systems. By embracing this more comprehensive approach, the GHSI can evolve into a more robust and reliable instrument for global health preparedness, ultimately strengthening resilience against future pandemics.

Ethical Approval

As this study is a scoping review, which involves the synthesis and analysis of existing literature rather than the collection of primary data from human subjects, ethical clearance was not required.

Availability Data and Materials

Since this study is a scoping review, all data and materials utilized are sourced from published literature.

Competing Interests

The authors declare that they have no relevant financial or non‑financial interest to disclose.

Funding

The authors declare that the research work was not funded by any grants or similar support.

Author’s Contributions

WH contributed to the methodology and supervised the scoping review process. VR was responsible for reviewing and editing the manuscript. DDC and KMO were involved in the investigation process, including screening, data extraction, and data synthesis. SJK, THK, SGL, and SYJ played a critical role in revising and refining the manuscript, providing feedback throughout multiple revision stages until the final version. DIP provided conceptualization of the study, contributed to the methodology and investigation (screening, data extraction, and data synthesis), and wrote the original draft of the manuscript.

Abbreviations

COVID‑19: Coronavirus disease 2019

GHS: Global Health Security

GHSI: Global Health Security Index

SARS: Severe Acute Respiratory Syndrome

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