Economic growth in the GMS is highly vulnerable to outbreaks of emerging diseases, such as severe acute respiratory syndrome, avian influenza, and Middle East respiratory syndrome. Other communicable diseases, including drug-resistant malaria, dengue, and antimicrobial-resistant infections, also have a significant economic impact. Multiple factors play a role in spreading communicable diseases, including an increasingly mobile population, increasing trade, and intensified interaction between people and animals. Particularly at risk are the poor, ethnic groups, and those living in border and remote areas or living along economic corridors. Infections can therefore easily pass beyond borders, and a regional approach is (i) necessary, so at-risk countries can participate and work together to improve their health systems; and (ii) beneficial, since it can result in synergies arising from coordination and lessons learned from regional peers.

In recent years, the ministries of health (MOHs) in GMS countries have made progress in regional information sharing, inter-sectoral dialogue, and cross-border cooperation for communicable disease control (CDC). Cross-border collaboration between neighboring provinces across international borders (which includes joint outbreak investigation, information exchange, and patient referrals) is gaining momentum but needs to be integrated into routine CDC activities.

Health service networks within Cambodia, the Lao PDR, Myanmar, and Viet Nam (CLMV) have expanded rapidly, but marginalized, mobile, and poor people still have limited access to health services. Mobile populations, ethnic minorities, and other vulnerable groups (MEVs) and populations living in remote border areas are more likely to spread infectious diseases and tend to use health services less than the general population. Cross-border migrant workers returning home with HIV or tuberculosis infection have limited access to treatment. Disease control programs for HIV/AIDS, tuberculosis, and malaria are in place but often do not reach these vulnerable groups in border areas due to staff and funding constraints. Consequently, in some countries, up to one-third of tuberculosis cases are not identified, and one-third of diagnosed tuberculosis and HIV/AIDS cases are not properly treated.

The MOHs have implemented surveillance systems for notifiable diseases and syndromic reporting to improve reporting of events and identification of cases from the community level. However, the disease surveillance system needs further digitalization and extension to all health centers, and syndromic reporting needs to be rolled out nationally. Further, MOHs must strengthen data management and analysis. Linkages and integration between disease surveillance, district health management information, and zoonotic disease surveillance needs to be improved. MOHs have to improve their capacities for risk analysis, community preparedness, and disease outbreak response. Outbreak district response teams are often poorly equipped and financed, and need capacity building on outbreak investigation and management.

Governments’ and development partners’ investments have improved laboratory services in provincial hospitals. In contrast, district hospital laboratories are unable to comply with internationally acceptable biosafety standards or to guarantee the accuracy of their laboratory tests. Underlying problems include substandard training of laboratory staff, and insufficient equipment and supplies. Formal processes for internal and external quality assurance are lacking. Laboratory auditing for compliance with quality and safety guidelines does not exist.

Hospitals and health centers are most likely to receive patients with emerging infectious diseases, but IPC practices in health facilities are substandard. Hospital sanitation and hygiene facilities are lacking. Hospital medical waste management is often unsatisfactory. The general public has almost unrestricted access to infectious patients wards, and such practices may result in ineffective treatment, the spread of emerging infectious diseases from health facilities to the general public, increased hospital-acquired infections, and development of drug resistance.

Weaknesses in CLMV’s health systems are a threat to health security in the GMS, one of the targets of the UN sustainable development goals for the health sector. The governments have demonstrated strong commitment and leadership towards the control of emerging infectious diseases and other diseases of regional importance. National policies and plans are in place to deal with these major health threats. CLMV countries have stepped up domestic financing and mobilization of external assistance to improve cross-border cooperation and put in place comprehensive national health security systems. CLMV are committed to achieve standards based on the International Health Regulations, 2005 in line with the strategic framework of the Asia Pacific Strategy for Emerging Diseases (APSED), 2010, both of the World Health Organization (WHO). The APSED, 2010 includes eight focus areas: (1) regional preparedness, alert, and response; (2) surveillance, risk assessment, and response; (3) monitoring and evaluation; (4) risk communication; (5) laboratories; (6) IPC; (7) zoonoses; and (8) public health emergency preparedness. CLMV governments have developed or are developing national strategies to increase quality of laboratories and IPC, based on WHO guidelines.

The midterm review of Strategy 2020 of the Asian Development Bank (ADB) recommends expanding operations in the health sector to 3%–5% of ADB’s annual approvals. The project is in line with ADB’s Operational Plan for Health, 2015–2020. The project is included in the current country operation business plans of CLMV and in the GMS Regional Investment Framework Implementation Plan, 2014–2018; and is aligned with the CLMV country partnership strategies. The project addresses regional public goods as described in ADB’s regional cooperation and integration strategy. ADB financing in the GMS health sector includes engagement in supporting regional cooperation, infrastructure development projects, human resources development, and a health sector governance reform program. ADB has supported several loans and grants focusing on CDC; multiple loans, grants, and technical assistance projects focusing on HIV/AIDS; and a number of grants and technical assistance projects focusing on malaria financed under ADB’s Regional Malaria and Other Communicable Disease Threats Trust Fund under the Health Financing Partnership Facility.

Earlier ADB GMS projects on CDC have supported regional cooperation, equipped provincial health facilities, and focused on addressing single diseases (malaria, HIV/AIDS, and neglected tropical diseases). Building on the lessons learned from previous interventions, the project will focus on (i) overall health system strengthening, rather than concentrating on a single disease; (ii) streamlining support for regional cooperation with existing regional frameworks such as the APSED; (iii) supporting district health facilities close to remote populations rather than provincial health facilities; (iv) combining equipment investments with improvement of the quality of laboratory diagnostic and health services in the district hospitals; (v) focusing on MEVs; and (vi) uniting separate CDC health interventions on single diseases into one investment focusing on preventing and mitigating the risk of adverse public health events that endanger collective health.

Other development partners that play an important role in CDC are the United States Agency for International Development, which is rolling out the Global Health Security Agenda; the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria; the Three Millennium Development Goal Fund in Myanmar; WHO for CDC and health system technical support; the Global Alliance for Vaccines and Immunization and the United Nations Children’s Fund (UNICEF) for immunization; and the World Bank for hospital infection control in Viet Nam. So long as funding concentrates on HIV, malaria, and tuberculosis, it remains inadequate. As CLMV’s national income per capita increases, future financing by the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria, and bilateral development partners is uncertain. Aid coordination mechanisms are improving at the central level, across subsectors, and increasingly also at the provincial level.

CLMV governments have requested ADB support for the GMS Health Security Project. The project will expand surveillance and outbreak response systems, improve data management, shift from expanding laboratory services to improving laboratory quality and biosafety, and add support for rolling out IPC to all hospitals in the target provinces.

The impact will be strengthened GMS public health security. The outcome will be improved GMS health system performance with regard to health security. The project locations are selected provinces along the borders and economic corridors. In these locations, health facilities typically serve not only the local population but also mobile and migrant populations in the region. Selection of project provinces is based on (i) economic status of the province; (ii) health and health services statistics; (iii) regional risks and priority clusters; and (iv) existing support from other development partners. The project will cover 13 provinces in Cambodia, 12 provinces in the Lao PDR, five states and regions in Myanmar, and 36 provinces in Viet Nam.

The project will have 3 outputs:

Output 1: Regional cooperation and communicable disease control in border areas improved. This output will strengthen APSED focus areas 1, 3, and 4 (para. 7). Under this output, the project will strengthen (i) regional, cross-border, and inter-sectoral information sharing and coordination of outbreak control among GMS countries, (ii) regional capacity for evidence-based CDC, (iii) development of better disease control strategies for MEVs in border areas, and (iv) improved CDC services for MEVs in hotspots along economic corridors in targeted border areas. The project will provide support for cross-border activities (including simulation exercises, and joint outbreak investigation and control), information exchange, inter-sectoral collaboration, strategic planning, disease control strategies for MEVs in border areas, outreach to MEVs, and improving access of MEVs to CDC services. The regional coordination unit, hosted by the MOH of the Lao PDR and financed under a regional technical assistance project, will provide technical support to CLMV for information exchange, disease control strategies for MEVs, and organization of regional events.

Output 2: National disease surveillance and outbreak response systems strengthened. This output will strengthen APSED focus areas 1, 2, 3, 7, and 8 (para. 7). Under this output, the project will support (i) syndromic reporting at the community level; (ii) web-based reporting; (iii) linking of disease surveillance systems, including between clinical and laboratory surveillance; (iv) improving capacity for risk analysis, risk communication, and community preparedness; (v) improving capacity of outbreak response teams, including transport and equipment; and (vi) improving screening and quarantine capacity at border entry points and quarantine centers. The project will provide expertise for system design, capacity building, information technology equipment, vehicles, and equipment for screening and outbreak control.

Output 3: Laboratory services and hospital infection prevention and control improved. This output will strengthen APSED focus areas 3, 5, 6, and 8. Under this output, the project will support improving biosafety and quality of laboratory services, and expanding services for CDC. Project inputs will include (i) conducting staff training for provincial and district hospitals for internal quality improvement; (ii) preparing standard operating procedures; (iii) providing basic equipment, supplies, and minor repairs for laboratories and schools; (iv) setting up external quality assurance and audit systems for compliance with national biosafety and quality guidelines; and (v) setting up laboratory networks. The project will improve IPC at district hospitals through training in hospital hygiene and case management, provision of basic equipment, and minor repairs of wards.