(DRAFT) Strategic Plan

Zero Draft 01/04/17

This is a working document, intended to steer discussions regarding the development of a National Public Health Agency for Sierra Leone

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ContentsIntroduction...........................................................................................................................................4

Forward.............................................................................................................................................4

Purpose..............................................................................................................................................4

Scope.................................................................................................................................................4

Country Context....................................................................................................................................5

Public Health Background......................................................................................................................5

Health Outcomes...............................................................................................................................5

Legislative and policy context............................................................................................................6

Healthcare Provision..........................................................................................................................6

Public Health Infrastructure..............................................................................................................7

Moving Forward................................................................................................................................7

Organisational Overview.......................................................................................................................9

Jusification.........................................................................................................................................9

Vision...............................................................................................................................................10

Mission............................................................................................................................................10

Guiding Principles............................................................................................................................10

Core Values......................................................................................................................................11

Functions of the Agency......................................................................................................................12

Approach.........................................................................................................................................12

Goals of the NPHA...........................................................................................................................12

Organisation of the NPHA....................................................................................................................13

Surveillance.....................................................................................................................................13

Public Health Laboratory Services...................................................................................................15

Public Health Emergency Operations..............................................................................................16

Public Health Workforce Development...........................................................................................17

Public Health Research....................................................................................................................18

Health Promotion............................................................................................................................21

Proposed physical location of the Agency...........................................................................................23

Organizational Position of the Agency.................................................................................................23

Suggested coordinating components..................................................................................................23

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Executive Summary

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Introduction

Forward(TBC)

Purpose This strategy document is designed to outline the functions and the Sierra Leone National Public Health Agency (NPHA) for Sierra Leone. It is intended to guide the Sierra Leone government, donors, partners and other stakeholders in prioritizing, developing and implementing activities for the NPHA over the coming three years (to 2017 to 2020).

Scope This plan draws heavily on previous work to develop an NPHA in Sierra Leone, as well as developments in other countries, particularly in West Africa. It is intended as a “version zero” of a developing strategic plan and will form the basis of discussions with stakeholders to form a definitive strategic and operational plan.

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Country ContextSierra Leone is located on the western coast of Africa, bordered by Guinea to the north and northeast, Liberia to the south and southeast, and the Atlantic Ocean to the west. Sierra Leone has a total area of 71,740 km2

It is divided into the Northern, Southern and Eastern provinces, and the Western Area, which includes the capital city of Freetown. The regions are divided into fourteen (14) districts, which are sub-divided into 152 chiefdoms, governed by local paramount chiefs. For district-level health governance, the Western Area Rural and Western Area Urban districts combine to comprise the Western Area Health district; the remaining twelve (12) health districts correspond to the national districts. There are fourteen (14) health districts.

Figure One: Districts of Sierra Leone

Public Health Background

Health OutcomesHealth outcomes in Sierra Leone are poor, with a life expectancy of 50 years at birth and under-five mortality and maternal mortality rates that are among the highest in the world.

Public Health in Sierra Leone must be viewed within the broad historical context of poverty and a high illiteracy rate (43 percent). Sierra Leone is recovering from multiple disasters: the civil war (1990–2002); the cholera epidemic (2012); and the EVD outbreak (2014-15). The country was deemed to have “not attained the minimum International Health Regulations core capacities by 2012”. Nevertheless, prior to the EVD outbreak in mid-2014, Sierra Leone had made substantial progress towards a number of the Millennium Development Goal targets in the health and nutrition sectors, including a reduction in child and maternal mortality and improving coverage with a range of critical interventions such as family

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planning, skilled birth attendance, and immunization. The recent National Nutrition Survey (2014) also demonstrated major improvements in nutrition levels.

Legislative and policy contextSierra Leone’s Public Health Ordinance of 1960 defines the powers of the state to regulate areas concerned with the public health such as sanitation, housing, infectious disease control and food safety. While there have been numerous amendments to the Public Health Ordinance 1960, the most recent being the inclusion of Ebola in the “notified disease” category in 2014, the ordinance is currently being reviewed to reflect current and historical developments and contemporary public health needs.

Framed alongside commitments articulated in the national development plans, the National Health Strategic Plan 2010–2015, Free Health Care 2010, the Basic Package of Essential Health Services 2010, and the National Health Compact 2011 provide overall guidance for health system strengthening and for improving the health status of the population. Health policies, programmes and coordinating structures, such as the Health Sector Coordinating Committee chaired by the Minister of Health and Sanitation, do exist, galvanizing cooperation among health, environment and development partners in the country. Sierra Leone is a signatory of the International Health Regulations (2005).

Healthcare Provision The health workforce is concentrated in the capital Freetown, where 50 percent of all health professionals work, serving just 16 percent of the population. There is a critical general shortage of health professionals (0.3 physicians per 10,000 people), and wage bill constraints limit public sector employment (despite a vacancy rate among health professionals of 54 percent). Despite efforts to improve the availability of services, including a network of nearly 1,200 Peripheral Health Units, and efforts to improve access – such as the Free Care Act, which reduces financial access barriers for pregnant women, lactating mothers, and children under five – gaps persist in the quality of care. Not least, the ability of health information systems to inform decision making is limited by the timeliness, completeness and quality of data.

Ebola has impacted significantly on the public health system of Sierra Leone. Health workers suffered disproportionate mortality during the EVD outbreak, owing to increased instances of exposure. The World Health Organisation (2015) estimates a ratio of 1444,000 people per trained doctor in the country. Concurrently, there has been noted reduction in health centre utilisation, institutional deliveries and childhood immunisation and treatment for malaria.

Capacity has also been diverted away from existing public health priorities such as immunisation and prevention of possible outbreaks of vaccine-preventable diseases (particularly measles). There has been a noted surge in malaria cases and deaths, acute malnutrition, and maternal/new-born deaths due to home deliveries. Concerted efforts to

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restore and scale up essential health services in line with the Basic Package of Essential Health Services will be a major challenge. Importantly, the outbreak underpins the need to have strong social capital, to engage communities in the planning and delivery of health services, and to integrate risk communication and social mobilization into health system strengthening.

Public Health InfrastructureHistorically public health programs in Sierra Leone could be characterized as being fragmented and siloed, which led to competition for limited resources. However, in the post-Ebola environment, Sierra Leone has made substantial progress in its upgrading public health systems through donor funded programs that have supported:

Updating the Integrated Disease Surveillance and Response System Updating the surveillance system to incorporate event-based, syndromic, and

indicators Creating, equipping, and training rapid response teams Updating the Preparedness and Response Plan Upgrading, equipping of public health laboratory and training laboratory personnel Establishing, equipping, training, and operationalizing the Emergency Operations

Center…

The November 2016 Joint External Evaluation found that Sierra Leone had multiple deficits in its compliance with the International Health Regulations, notably

Updating public health laws and legislation Formulation of a multi-hazard National Public Health emergency preparedness and

response plan that address ports of entry and integrates cross border collaboration Develop strategies and plans for antimicrobial resistance, detection, and mitigation Establish a comprehensive national biosafety and biosecurity system for both human

and animal health sectors Scale up the FETP program to cover intermediate and advanced courses for the

national and district level, including veterinary and laboratory staff Develop strategic plan, guidelines & SOPs to facilitate capacity building for

laboratory, syndromic surveillance & response to chemical hazards Establish a comprehensive national biosafety and biosecurity system for both human

and animal health sectors Accelerated the implementation of a One Health approach

The Sierra Leone NPHA will be a key component in building on these areas, strengthening integration and decision making across human, animal and environment health.

Moving ForwardWithout a dedicated focus on the public health infrastructure, systems and personnel in the country, Sierra Leone will struggle to maintain its development trajectory, ensure a robust

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Agenda for Progress and drive to Vision 2035, whilst securing compliance with the International Health Regulations and supporting achievement of the SDGs.

Within this context, in April 2015, President Koroma wrote to the head of CDC USA, Tom Frieden, requesting support for the establishment of a robust Public Health Oversight, monitoring and delivery system.

The Strategic Plan 2017-2020 has been developed with this context in mind. It builds on achievements and learnings to date and is designed to enable further health gains for Sierra Leone and to develop the NPHA organization, over the next three years.

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Organisational Overview

Jusification The Sierra Leone National Public Health Agency is a science based government organisation that serves as a focal point for leadership, expertise and coordination to address public health concerns in line with national public health needs and global health security requirements.

An organisational focus for evidence-based policy making and health systems strengthening enables a stronger and more consistent response to the public health threats that affect Sierra Leone. A coordinated, science-based SL NPHA enables GoSL to:

Comprehensively strengthen the public health system to predict, prevent, detect, respond and control disease.

Meet workforce needs Ensure effective coordination of donor funding for GHS, aligning support behind the

identified priorities of the NPHA Predict, plan for, and prevent endemic public health problems Prepare and respond to public health emergencies Ensure strategic use of resources to meet national public health priorities More effectively integrate evidence in policy and decision making Ensure functional areas are meeting national and international standards Meet International Health Regulations

In order to be successful, an NPHA requires:

Country Ownership – a strong institutional capability led and supported by Government of Sierra Leone

A high level champion Consistent political support to ensure allocation of resources to sustain functions Legislative framework to permit over Demonstration of high value impact using integrated M&E systems A clear evolutionary and implementation path Meaningful and effective engagement with stakeholders Strong NPHA Leadership and dedicated staffing.

A coordinated approach to health services and public health systems is more cost effective and efficient than simply investing in vertical, unconnected, and uncoordinated programmes. A national public health Agency is a sound and viable model for strengthening national public health infrastructure and capacity which has been tested in a number of countries. The NPHA, will contain certain core public health functions, whilst strengthening the collaboration and networking of MOH and other Ministries entities, through enhanced information sharing and analysis.

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The following statements were developed via a multi-stakeholder working group and reflect the core aspirations of the NPHA.

Vision The vision of the Sierra Leone NPHA is:

“A Healthy Sierra Leone through evidence based leadership in Public Health”.

MissionThe mission of the Sierra Leone NPHA is:

“To secure the health of Sierra Leone, as the trusted source of Public Health information, guidance and leadership”.

Guiding PrinciplesThe SL NPHA will adhere to the following core principles:

To operate with transparency, honesty, and equity To speak as the authority on behalf of the Sierra Leone’s public health system To only use and disseminate evidence-based public health information To serve as a credible authority for the development of well-informed public health

priorities, guidelines, policies, and programs To translate public health data and research into action To actively protect and promote the public health security of Sierra Leone To use fair and equitable means to prioritise programs and activities. The SL NPHA will ensure that data and information are used in the creation of better

policy and programs.

The Sierra Leone Ministry of Health plans to lead the collaborative effort for establishing an NPHA in Sierra Leone which will create the expertise, information, and tools that people and communities need to protect their health. Over three years, MOH will work with its technical partners to build institutional capacity through the development of an NPHA.

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Core ValuesCore values represent the durable and supporting qualities that shape and guide all activities that the Sierra Leone Public Health Agency will undertake. NPHA core values may include those listed below as well as others that the Ministry and stakeholders may develop over time.

Ethics and integrity: The NPHA upholds generally accepted high standards of ethical behavior. All those involved with the NPHA conduct themselves in a professional manner that reflects favorably on the agency and the Government of Sierra Leone.

Transparency: The NPHA communicates honestly and openly about its activities, their results, and their impacts on the health outcomes of Sierra Leonens.

Accountability: We set high expectations for the performance of the NPHA, take responsibility for what we do, and demonstrate that we use the resources entrusted to us to serve the people of Sierra Leone.

Equity: We openly recognize disparities within our organization and in the health outcomes of the people of Sierra Leone and are committed to reducing them and increasing equity for all.

Partnership: We recognize that sustainable success involves collaboration – among the staff of the agency, with other agencies of the Government of Sierra Leone, with communities, and with external partners -- based on mutual trust and respect, a shared vision and goals, commitment, and active participation by all involved.

Quality: The NPHA delivers high-quality public health functions, services, knowledge, and expertise.

Productivity: The NPHA generates tangible results that contribute to prevention and control of public health threats.

Innovation: The NPHA is a learning institution that takes pride in the ability and willingness of its staff to initiate innovative approaches that contribute to achieving the agency’s mission.

Gender: We work to ensure that the voices of women are heard and their needs met equitably with those of men, both within our organisation and through our work.

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Functions of the Agency

The NPHA will incorporate and consolidate a number of core public health functions, currently dispersed across the MoHS and other parts of GoSL :

Public Health National Reference Laboratory Public Health Surveillance activities Public Health Emergency Operations Health Promotion Human Resources for Public Health Public Health Research

ApproachIn carrying out the functions in this strategic plan, SL NPHA will:

Provide leadership in identifying and addressing Sierra Leone’s Public Health priorities. Integrate public health laboratory, surveillance and response functions Lead training and operational research regarding integrated functions Support agenda development for wider public health research, and data generation. NPHA or by partners with SL NPHA coordination Lead and support others in the analysis of data to identify trends and create evidence for

action Serve as a repository and analytical data center for public health data, information, and

research Ensure translation of data or other information into better public health policies and

programs

Goals of the NPHAThe following six strategic directions were identified and reached via consultation with stakeholders. Their order in no way reflects their importance.

A functional integrated public health surveillance system that provides timely evidence for public health action (prevention, detection and response).

An effective public health reference laboratory, linked to surveillance and capable of supporting ongoing improvements.

A health system that is able to effectively prepare for and respond to public health emergencies

A sustainable workforce, capacitated and skilled to meet the public health needs of Sierra Leone.

A strong and coordinated public health research capacity that informs policy and public health programs.

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Effective prevention of disease, through effective public health advocacy, education, services and policy development.

Organisation of the NPHAThe NPHA is an inline agency of the Ministry of Health and Sanitation, Republic of Sierra Leone, accountable to the Minister of Health and Sanitation and Chief Medical Officer.

Figure 2: Organisation of the NPHA

Echoing the Sierra Leone Health Sector Operational Plan, Assumptions underlying implementation of the plan are political stability and political leadership; effective public and private sector commitment to health; economic growth and continuity of international financial assistance; commitment to good governance; civil society and stakeholder engagement in health, especially at the community level; and effective partnerships among stakeholders.

Surveillance

Goal

A functioning, integrated public health surveillance system that provides timely evidence for public health action (prevention, detection and response) across GoSL.

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BackgroundThe NPHA will integrate the range of public health surveillance functions currently undertaken across the MoHS and other parts of GoSL.Public health surveillance is the continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice. Effective Public Health relies on having community, district and national infrastructure, communications and information technology, and linkages to the health care system to rapidly identify disease outbreaks. It also requires effective collaboration and data sharing within the health sector and between other sectors such as the agricultural and environmental sectors.

Each level of the system, from the community to national, will have the capacity appropriate to its level to collect and analyse surveillance data, and mount a response if an outbreak is identified. The national level will provide support to subnational levels in surveillance and response, as well as conducting combined data analysis and providing regular feedback to subnational levels. The NPHA will work to promote integration of surveillance data across multiple sectors and to use the data to forecast or prevent public health events. Working with partners, it will build a robust surveillance data that can be collated, analysed and used to predict and prevent outbreaks or other public health events and drive public health action.

A multi-faceted strategy is required to ensure that epidemic-prone conditions can be detected, confirmed, and addressed early. This requires that the Ministry of Health and Sanitation, SLNPHA and supportive partners focus its efforts to implement the procedures necessary for a prompt response, ultimately limiting the spread and impact of disease when an outbreak occurs. In keeping with the Sierra Leonean Presidential Recovery Plan, this will require building IDSR and multi-sectoral early warning systems from the community up through the national level of the surveillance system. Once in place, these systems will ensure that the local health infrastructure is prepared to recognize epidemic-prone diseases and other public events when they occur.

Strategic Objectives:

Integrate and strengthen surveillance activities from across GoSL. Deliver timely, relevant and high quality evidence to inform public health action. Undertake ongoing, multi-partner evaluation of surveillance systems to assess data

quality, relevance, timeliness and use, in order to inform investment and ongoing improvement.

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Public Health Laboratory Services

Goal

An effective public health reference laboratory, linked to surveillance and capable of supporting ongoing improvements.

BackgroundPublic Health Laboratories operate as a first line of defense to protect the public against diseases and other health hazards. Working in collaboration with other arms of the nation’s public health system, public health laboratories provide clinical diagnostic testing, disease surveillance, environmental and radiological testing, emergency response support, applied research, laboratory training and other essential services to the communities they serve. Public health laboratory scientists are highly educated specialists with knowledge of one or more scientific disciplines, advanced skills in laboratory practice and the ability to apply this expertise to the solution of complex problems affecting human health.

The Agency will include the National Public Health Reference Laboratory, capacitated to test for, and aid in the diagnosis of usual, unusual and emerging pathogens; chemicals and other contaminants and pollutants. The national reference laboratory will confirm atypical laboratory test results, verify results of other laboratory tests and test epidemiologically significant specimens with potential public health implications.

In addition, the National Public Health Reference laboratory will provide reference diagnostic testing to laboratories not fully capacitated to identify disease agents of public health significance and ensure quality control/quality assurance for laboratory procedures.

Through linkages with the national surveillance and response functions within the Agency, the laboratory will support investigations of public health problems, hazards, and emergencies.

Strategic Objectives

Function as an accredited Public Health Reference Laboratory Develop and assess tools for the testing of pathogens of public health interest Support wider diagnostic capacity within Sierra Leone through ongoing quality

Assurance and training. Undertake Public Health research

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Public Health Emergency Operations

Goal

A health system that is able to effectively prepare for and respond to Public Health Emergencies

Background

The International Health Regulations (IHR 2005) request that States Parties develop, strengthen and maintain their capacity to respond promptly and effectively to public health risks and public health emergencies of international concern. The emergency Operating Centre facilitates the assembly of Public health emergency management personnel, to coordinate operational information and resources for strategic management of public health events and emergencies.

Emergency response, and the management of an Emergency Operations Center (EOC), is closely linked to surveillance, routine outbreak response, and follow-up. Routine outbreak response and follow-up provides practice and linkages that support effective response during a major outbreak.

At the national level, the NPHA will have the capacity to respond to outbreaks, including conducting investigations and recommending interventions. Routine outbreaks provide practice runs for larger responses.

Strategic Objectives:

Ensure the functioning of EPRR infrastructure at the local and national level, including an effective EOC.

Develop policy and governance for EPRR at a local and national level Develop EPRR capacity at a local and national level Provide Audit and testing EPPR capability at a local and national level

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Public Health Workforce Development

Goal

A sustainable workforce, capacitated and skilled to meet the public health needs of Sierra Leone.

BackgroundA strong public health system requires workers with training in a wide range of fields, including epidemiology, laboratory sciences, health policy, health communications, information technology, and management. It is the NPHA's responsibility to help develop a public health workforce that is adequate for national needs, both for the NPHA itself and to support the broader public health infrastructure.

This responsibility might include monitoring the workforce in terms of existing capacity and unmet needs, providing training and continuing education for NPHA employees or other public health professionals (for example, in laboratory techniques or epidemiology), advocating for strong public health departments in universities, forming partnerships with universities and other places where public health training is conducted, and defining licensure requirements for public health professionals.

Retention of skilled public health workers is also important. Public health work may pay less than work in the private sector, and skilled workers in low-resource countries may seek opportunities in higher resource countries. The NPHA will play a role in helping to provide fulfilling opportunities for public health practitioners and other incentives for remaining in the public health workforce. The mix of activities related to workforce will focus on training that is practical and provides specific skills in public health.

Strategic Objectives

Undertake ongoing assessment of public workforce needs, to include evaluation of current training provision.

Co-ordinate a multi-partner workforce development strategy to proactively meet public health workforce needs.

Support and advocate for partner institutions to ensure that appropriately trained and experienced staff are available in sufficient numbers to meet public health needs.

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Public Health Research

GoalA strong and coordinated public health research capacity that informs policy and public health programmes

BackgroundConducting research is a critical public health function and is important for the credibility of a public health agency.

The Agency will establish a research agenda that includes operational and original research leading to findings of national and international importance. Research will be undertaken collaboratively, with national and international partners, enhancing the quantity and types of data collected and the relevance of the work. The NPHA will have sufficient resources to carry out its research agenda, by conducting the work itself and by supporting other partners who have specialized expertise, links to populations of concern, etc. Priorities reflecting the JEE suggest that cross-sectoral collaboration on research should be included to be able forecast, model, or prevent outbreaks

The recent Ebola outbreak demonstrated the capacity of Sierra Leone to provide leadership in the development of a research agenda to address important questions regarding prevention and treatment of the disease as well as a better understanding of the long-term health consequences in survivors. This research agenda is important not only to the people of Sierra Leone, but also this region of Africa, as well as the rest of the world. The development of research capacity will help to inform public health policy and practice, generate hypotheses and questions for further research and serve as a basis to demonstrate capacity in seeking external research funding.

With health care delivery a more immediate need for the Ministry of Health and Sanitation, a comprehensive, long-term approach to funding research is needed, especially as current research efforts are funded through research partners in response to the Ebola epidemic. Raising the potential for both internal and external funding is dependent upon the demonstration of research accomplishments through near-term publications and the presentation of a research agenda responsive to the needs of Sierra Leone and of interest to potential future partners.

Strategic Objectives

Strengthen national capacity to initiate or participate in epidemiological and public health research.

Develop and implement an agenda for research in public health based on population need and key actors in public health produced.

Identify and disseminate research based solution to health problems Assess the effectiveness /feasibility of new technologies and tools

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Strengthen policy and/or programming in the field of public health, through the use of research evidence.

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Health Promotion

Goal

Effective prevention of disease, through effective public health advocacy, education, services and policy development.

Background

Sierra Leone, as with other countries in West Africa, finds itself entering an epidemiologic transition. Whilst infectious disease remains the largest contributor to morbidity and mortality, Non-Communicable Diseases (NCDs), including mental illness, are of considerable concern. Under-nutrition remains a chronic issue for many in Sierra Leone, but over nutrition, leading to diseases such as diabetes, heart disease and stroke, is a significant and growing concern. Cancer has recently been declared a public health emergency.

Non-communicable disease risk factors are modifiable; however, people may lack the knowledge, resources and agency to do so without support.

In turn, rates of infectious disease can be reduced markedly through education and appropriate policies, particularly with regards to Water and Sanitation for health and environmental management. However, these may require significant investment and advocacy to ensure that infrastructure is effective in preventing and mitigating outbreaks of disease.

Ebola highlighted the impact of communication and collaboration in controlling the spread and impact of disease. The recent Joint External Evaluation (JEE), assessing compliance with the International Health Regulations (IHR) made a number of recommendations for developing cross sectoral co-operation and consolidation of effort to address the risks of emerging infections, zoonoses and Anti-Microbial Resistance (AMR).

As the trusted source of public health guidance and leadership in the country, the Agency has a key role in supporting and co-ordinating efforts to prevent and reduce the impact of disease, undertaking and supporting research to inform health promotion activities, advocating for and enabling the formation of evidence informed policies and providing recommendations to relevant programs and partners to promote the public’s health.

Strategic Objectives

Develop and implement a national disease prevention strategy Develop a framework for adoption and implementation of international public health

policies and strategies.

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Develop and strengthen effective mechanisms to create and maintain supportive environments for health improvement.

Strengthen M&E and research mechanisms to assess the impact of public health interventions and policies.

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Proposed physical location of the AgencyThe Sierra Leone Public Health Agency is expected be physically located in the Emergency

Operations Centre building, Wilkinson Road, Freetown.

Organizational Position of the AgencyThe Agency is expected to either be part of the Ministry of Health and Sanitation, Republic

of Sierra Leone, or to exist as an autonomous entity, accountable to the Minister of Health

and Sanitation. The determination process will be led by the leadership of the Executive

Branch and the Ministry of Health and Sanitation after taking into consideration inputs from

appropriate Sierra Leonean legal counsel. The Republic of Sierra Leone is engaged in a

process to amend or create legislation that will codify the decision made by the leaders,

which will require a cabinet memo in the instance of the NPHA sitting within the Ministry, or

legislation were the agency to be constituted as a parastatal.

Suggested coordinating componentsThe centre shall have the following coordinating components.

a. Infectious diseases, including the immunization program, sexually disease infections, Tuberculosis, and HIV prevention.

b. Support the development of a national reference laboratory. It shall support other centers with laboratories, ensuring that they are well-equipped and staffed with well trained and experienced personnel. The National Reference Laboratory shall support epidemic investigations, epidemic prone diseases and the bureau of standards as well as chemical investigations.

c. Health information and services: provide information and statistics on key diseases for the health professionals, health planners and decision makers. It will provide professional support to the MOHS. Epidemiology and biostatistics will be based in this unit.

d. Health Promotion, which should include prevention of non-communicable diseases other than cancer. Special emphasis will be placed on cardiovascular diseases, nutrition problems, diabetes, and geriatrics.

e. Maternal, newborn and child health (MNCH)f. One Health and Global Health Security.

Additional coordinating components shall be added as deemed appropriate

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