Regional : Greater Mekong Subregion Health Security Project

Health / Health system development

The Greater Mekong Subregion (GMS) Health Security Project is composed of (i) four loans to Cambodia, the Lao PDR, Myanmar, and Viet Nam (CLMV); and (ii) a grant to the Lao PDR. The project builds on previous and ongoing interventions focusing on communicable disease control (CDC) in Cambodia, the Lao PDR, and Viet Nam; and now including Myanmar.

The impact will be GMS public health security strengthened. The outcome will be GMS health system performance with regard to health security improved. The project has three outputs.

"Output 1: Regional cooperation and communicable disease control in border areas improved.

"Output 2: National disease surveillance and outbreak response systems strengthened.

"Output 3: Laboratory services and hospital infection prevention and control improved.

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. Traditional communicable diseases, including drug-resistant malaria, dengue, and antimicrobial-resistant infections, also have a significant economic impact. Health systems weaknesses in CLMV are a threat to health security in the GMS, one of the targets of the United Nations sustainable development goals for the health sector. The project will address key binding constraints in the countries' health system and promote cross-country cooperation aimed at improving both national and international health security.

Health service networks within CLMV have expanded rapidly, but marginalized, mobile, and poor people still have limited access to health services. Disease control programs are in place but often do not reach these vulnerable groups in border areas due to staff and funding constraints.

Surveillance systems for notifiable diseases and syndromic reporting are being implemented in these four countries. Health authorities in CLMV have to increase their capacities for risk analysis data management, 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.

Past 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. 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 receive patients with emerging infectious diseases, but infection prevention and control practices in health facilities are substandard. Hospital sanitation and hygiene facilities are lacking. Hospital medical waste management is often unsatisfactory. Such may result in ineffective treatment, the spread of infectious diseases, increased hospital-acquired infections, and development of drug resistance.

GMS public health security strengthened

GMS health system performance with regard to health security improved

MYA:

- Checklist for auditing quality & biosafety will be developed based on NHL checklist in Mar 2019

- Site specific Laboratory and IPC assessment were done during Feb and March 2018 and assessed health care waste and its management. It was re-assessing again for internal audition on relevant quality & biosafety components in May-July 2019

- Procurement of lab equipment and equipment for isolation ward for regional and district labs (NCB 3, 5, 6, 9) were accomplished in AOP2.

- National Workshops on quality and biosafety, Laboratory trainings for Test Kit evaluation, NEQAS, Lab training for antibiotic susceptibility testing were conducted.

- Study visit and initial assessment for ISO 15189 were conducted in 2019.

- Printing and dissemination of Laboratory Quality Checklist, Laboratory Biosafety Checklist and SOP on Collection, Storage and Transportation of Infectious Disease Specimens Books to all Public Hospital Laboratories

- National Workshop for action plan on IPC at hospitals, Case Manage training, training of Surveillance on HAI and patient safety curriculum were conducted.

- International short course training on IPC to Bangkok, Thailand was conducted.

- IPC committee meetings were conducted and plan to do so quarterly in AOP3.

- preparation for 2018-2019 audit Meeting with Biosafety Expert for detail planning of ToT Biosafety Curriculum Training in March 2020

- 1st Asia Pacific Society of Infection Control training in Nonthaburi, Thailand was attended

- Preparation of two Research Proposals for AMR and Point Prevalence survey for ethical review committee

- Training on understanding ISO 15189 for capacity building and onsite advisory visit was conducted in Dec 2019

Regional cooperation and CDC in border areas improved

National disease surveillance and outbreak response systems strengthened

Laboratory services and hospital IPC improved

Emergency preparedness and response capacity for COVID-19 strengthened

CAM:

- MOH developed Cambodia Laboratory Quality Management System (CamLQMS).

- Laboratory staff will be trained in 2020 according to CamLQMS standard to audit laboratories

- The training on laboratory auditing is planned in NIPH for AOP 2020.

- The trained laboratory staff will audit lab for quality and biosafety by 2020.

LAO:

16/74 district labs audited in last 12 months before Feb 2018 (21.6%)

18/30 central prov labs audited (60%)

Self-assessment survey in Feb 2018

35/42district labs (83%) audited in last 12 months. 8/12 prov labs audited (67%)

Project survey in Aug 2018

Survey will be repeated during project implementation and at end

MYA:

- All targeted laboratories have been audited in 2018 and 2019 for quality and biosafety.

- Various sections within NHL are responsible for follow up the audit recommendations.

VIE:

In 2019 144 district laboratories (out of 208 providing data) had been audited once for quality and biosafety by the Provincial Health Department (hospitals undertake self-audit annually).

In 2019 7/8 TOT courses on laboratory quality management and biosafety were implemented.

Training for provincial and district staff on laboratory quality management and biosafety is implemented under AOP 2020

Provincial Health Departments will continue to implement laboratory audits based on the provincial plan.

CAM:

SOP is being implemented separately by vertical programs.

MOH completed final version of national SOP to be signed in Q1-2020.

LAO:

26/74 district labs have SOPs (35%)

16/30 central prov labs have SOPs (53%)

Project survey in Feb 2018

MYA:

- With the support from the project, the SOP on specimen collection, storage and transport was developed by NHL in April 2018.

- Targeted laboratories were also trained for development of SOP for collection, packaging, storage and transport in August 2018.

- The project also supported to update SOPs for IPC in April 2019.

- The laboratory and IPC guidelines were printed and disseminated to target hospitals in September 2019.

In 2018, 5 hospitals' lab developed own SOP (Mawlamyaing, Hpa An, Dawei, Lashio, Loikaw)

In 2019, 6 hospitals' lab has own SOP for lab (abve 5 plus Myawaddy)

VIE:

By 2019 143 district laboratories (out of 208 providing data) have developed SOP for collection, packaging, and transportation of biological samples.

SOP for sample collection and technical testing will be disseminated under the laboratory training program implemented under AOP 2020

CAM:

-There are 2 training on bio safety conducted with participants in total 53 (Female:15). There are 38 (Female:10) achieve the competency requirement score.

-53 Laboratories targeted by the project have total laboratory staff 258 (Female: 85) in 2018.

2019:

-Q3: There is ToT training on Biosafety and bio risk management with total participant 39 (Female:6).

-45 of 53 target hospitals have appointed female staff.

Overall 15 (currently project cover 53 hospitals) female staff have met the national laboratory biosafety and competency.

LAO:

30/93 labs with 2 staff (I or more female) meet the standards (32.2%)

Project survey in Feb 2018.

Biosafety training easier to measure suggest indicator is staff trained in BS

MYA:

- NHL conducted the TOT training on laboratory biosafety in September 2019. 10 participants attended the training, among which 8 were female. The competency assessment on biosafety requirement was conducted before and after the training and assessment score showed significant increase in biosafety competency after the training.

- NHL also organized lab quality trainings (SOP training, National Lab training in 2018) with 1 person each from 12 townships (10 F, 2 M).

- In 2019, NHL organized lab quality trainings (Antimicrobial susceptibility training, NEQUS trainings) with 1 person each from 12 townships ( 9 F, 3 M)

VIE:

At MTR the means of measurement for this indicator was revised to assessment of staff competency undertaken as part of the laboratory training program.

Training for district laboratory staff on biosafety will commence in Q1 2020. Therefore, no data is as yet available for this indicator

CAM:

Health Information System (HIS) are using in all targeted operational districts (OD). The health facility data is sending to Department of Planning and Health Information (DPHI) including the data on communicable diseases are classified by sex.

In Communicable Diseases Control Department (CDCD) all CDC surveillance electronic report are classify by sex.

In 2019, Cambodia worked with ADB to prepare the concept note and ToR for recruiting international consultant for developing dashboard which integrated 3 systems including CamEWARN, HIS and CamLIS together for response with diseases outbreak. The International consultant already recruited in Q1-2019. Beta version of the software was developed in Q3-2019.

In overall all target 46 operational districts have sent electronic data with sex disaggregated through HIS.

LAO:

Currently all outbreak data are sex disaggregated and electronic.

Disease information sharing continues among CLMV countries

MYA:

- Sex-disaggregated data format is included in DHISII software for monthly electronic reporting on 17 Communicable Diseases Under National Surveillance (DUNS)

- Weekly integrated disease surveillance for AFP, Measles, Neonatal Tetanus, influenza like illness and other VPDs include sex-aggregated data.

VIE:

In 2019, 157 districts (out of 226 districts providing data) send sex-disaggregated electronic report on communicable diseases as per national regulations.

In 2019, 100% (250/250) of DHCs have had staff trained in the use of infectious disease reporting software following the requirements of Circular 54/2015/TT-BYT, including reporting of sex disaggregated data.

13 provinces have implemented training for 3964 district and commune health staff and village health volunteers responsible for surveillance data collection and data analysis (female = 2256 (57%); EM = 1159 (29%)).

CAM:

In 2018 and 2019, all outbreak response reports indicate appropriate measure. Appropriate measure refers report follows CDC department surveillance and response SOPs. (1) Detect cluster, (2) verify clusters, (3). Conduct risk assessment, (4). Form outbreak response team, (5) written report (Primary report, descriptive report or scientific report).

In 2018:

There were 56 outbreaks occurred in nationwide include 29 in 11 targeted project provinces.

In 2019:

In Q1: There were 30 outbreaks occurred in nationwide include 22 in 8 targeted project provinces (Svay Rieng, Kandal, Banteay Meanchey, Rattanakiri,Tbong Khmum, Prey Veng, Kratie and Battambang). During these outbreaks, there were 514 cases (Female: 298) and leave 13 (Female: 8) people died whereas target provinces occurred 494 case (Female: 283) including 6 (Female: 3) died

In Q2: There were 15 outbreaks occurred in nationwide including 10 in 7 target provinces (Banteay Meanchey, Battambang, Kratie, Prey Veng, Svay Rieng, Stung Treng and Tbong Khmum). Those outbreaks are rabies, food poisoning, acute diarrhea, and mass faiting. There were 163 cases (Female:98, IP:0) and leave 8 people died (Female:3, IP:0) whereas target provinces had 104 cases (female: 26, IP:0) including 5 people died (Female:1, IP:0).

In Q3: There were 6 outbreaks occurred in nationwide including 4 in 2 target provinces (Battambang and Kandal). Those outbreaks are food poisoning and mass faiting. There were 132 cases (Female:98, IP:0) and leave 2 people died (Female:1, IP:0) whereas target provinces had 123 cases (female: 89, IP:0) including 1 people died (Female:0, IP:0).

In Q4: There were 9 outbreaks occurred in nationwide including 6 of 4 target provinces (Svay Rieng, Battambang, Banteay Meanchey, Tbong Khmum). The outbreak are food poisoning, mass fainting, and complicated pneumonis. There were 409 cases (Female:149) and leave 3 people die (Female:0) whereas target provinces had 372 case (Female:129) including 2 people died (Female:0).

LAO:

Lao RRT and S&R staff utilise outbreak protocols. Checklists and SOPs used by RRT staff in outbreak investigations.

In 2018, 47 outbreaks 45/47 (95.7%) reported within 24 hours; 38/47 (80.8%) investigated within 24-48 hours; and 38/47 (80.8%) compliant with RRT SOP.

Jan-Dec 2019: 34/37 reported within 24 hours (92%); 32/37 followed up within 24 hours (85%) and 37/37 (100%) compliant with RRT SOP

MYA:

- CEU defined appropriate measures as reporting and investigation outbreak within 48 hours, conducting risk assessment, rapid response and risk communication.

- In 2018, about 500 among all 629 outbreaks and response (79%) reported to CEU according to National Protocol and procedures especially completeness of report

- In 2019, 536 among total 598 outbreaks (89%) reported to CEU according to National Protocol

- The outbreak response to Measles, DHF, Polio, Schistosomiasis and Diphtheria were supported by project in 2019.

- The project also supported emergency responses for flood and landslide in 2019 in Mon and Kayin States.

VIE:

In 2019, 99.2% (11,165 / 11,258) of outbreaks were managed within the required timeframe.

CAM:

Cambodia provide the report of 7 epidemic prone diseases and syndromes on weekly basis which posted on CDC department website http://cdcmoh.gov.kh/surveillance/camewarn.

LAO:

Lao uses standard WHO case definitions and has 17 notifiable diseases as well as EWARN reporting.

Disease Info Exchange between CMV identifies 13 agreed core diseases and outbreaks are reported weekly and monthly between the countries

MYA:

- The EA is currently reporting 17 diseases under the surveillance system.

- The project is implementing the SOP for communicable diseases, which include WHO standard case definition for surveillance and reporting.

- The EA used IHR annex 2 as standard reporting procedure for public health emergencies

- The EA hosted Regional Workshop for quarantine service, where priority notifiable diseases were identified between GMS countries.

VIE:

At the mid-term review the indicator was clarified, whereby harmonized case definitions' was defined as 'case-definition based on WHO case definitions, modified for country context.

In Viet Nam 9/9 Group A infectious diseases have case definitions that are harmonized with WHO case definitions.

Regional reporting follows the procedures for reporting to WHO in IHR Annex 2.

In 2020, PMU Viet Nam will coordinate with the regional health specialist to confirm diseases for which WHO case definitions are commonly applied by the four project countries.

CAM:

Information sharing:

5 of 13 provinces (Kampot, Kandal, Tbong Khmum, Stung Treng, Svay Rieng) have shared information of diseases with Vietnam and Lao PDR.

2018:

Attending cross border meeting:

1. Cross border central cluster provinces in Pakse on 29-30 Aug 2018.

2. Join simulation exercise on Avian Influenza in Pakse on 26-27 Sep 2018.

Hosting cross border meeting:

1. Cross border meeting for Southern cluster 1 province hosted by Kandal in 28-29 June 2018.

2. Join Simulation Exercise for Central Cluster Province hosted by Stung Treng Province on 24-25 December 2018.

Information sharing:

5 of 13 provinces (Kampot, Kandal, Tbong Khmum, Stung Treng, Svay Rieng) have shared information of diseases with Vietnam and Lao PDR.

2019:

-No cross-border meeting conducted by CLV in 2019.

-10 of 13 provinces (Kampot, Kandal, Tbong Khmum, Stung Treng, Svay Rieng, Rattanakiri, Preah Vihear, Pailin, Banteay Meanchey and Battambang) share information with Lao PDR, Vietnam and Thailand.

Overall 10 of 13 provinces implement cross border collaboration activities (information exchange) in 2019.

LAO:

PMM meeting in March 2019 identified 12 cross border meetings to be held. 11 target provinces conducted cross border district meetings in 2019

MYA:

In 2018,

- Myanmar has signed MOU between Thailand and China for cross border collaboration for ATM and other communicable diseases.

- Myanmar Thailand Bilateral Ministerial meeting was conducted in August 2018 and the MOU for cross-border collaboration was conducted.

In 2019,

- Hosting (3) Regional events (AMR, HAI, Simulation Exercise) and Participated (3) regional events (PMM meeting, Risk Communication, ICT application) in 2019

- Cross border collaboration meeting for disease surveillance was hosted at Myawaddy (MYA-THAI) in Sep 2019.

- Cross border Trilateral collaboration meeting for disease surveillance was hosted at Tachileik (MYA-THAI-LAO) in Nov 2019 and also attend Trilateral cross border meeting at Mae Sai in Dec 2019

VIE:

In 2019, 6 of the 12 target provinces e implemented a total of 11 cross border activities. In addition, one non-target province bordering PRC (Cao Bang) implemented 2 cross-border activities.

PMU will support PPMUs in target provinces under AOP 2020 for the implementation of cross-border activities.

e Viet Nam assesses this indicator for the 12 provinces with project districts bordering a project district of a neighboring country

The project is classified as category B for environment, as the project has components dealing with laboratory biohazards and hospital

solid and liquid waste management. Mitigation measures are included in the environmental management plan to address minor environmental risks. An initial environmental examination and an environmental assessment and review framework have been prepared.

The MOHs as executing agencies will undertake information disclosures on the Project and its benefits, including but not limited to information related to the RRP, EMMPs and GAP. Public disclosure of the project financial statements, including the audit report on the project financial statements, will be guided by ADB's Public Communications Policy (2011). After review, ADB will disclose the project financial statements for the project and the opinion of the auditors on the financial statements within 30 days of the date of their receipt by posting them on ADB's website. The Audit Management Letter will be not be disclosed.

Reaching isolated communities constitutes a challenge, but provinces will use well-tested existing channels to reach them, such as village health communities, village health workers/volunteers, and grassroots networks existing in the project sites. A variety of communication media that have been proven effective will be utilized which include public awareness campaigns, community outreach, targeted group discussions, thematic workshops at the national and regional levels, and cross-border meetings. Relevant communication materials and knowledge products will be developed for targeted audience and a project website will be maintained throughout the project duration with links to existing MOH websites. In addition, the provincial preventive health centers (in Viet Nam), the provincial health offices in Cambodia and Lao PDR, and the township health offices (in Myanmar), will inform the project stakeholders (including beneficiaries, local nongovernmental organizations, women's and youth unions) on the project activities and progress. Direct links with the communities will be provided by the existing networks of village health volunteers and community health workers.

The MOHs current website on CDC shall contain a page on the Health Security project which is accessible to the public to disclose various information concerning the project, including general information about the project, public procurement related to the project, project progress and contact details in English and their national language. The webpage shall also provide a link to ADB's Integrity Unit (http://www.adb.org/Integrity/complaint.asp) for reporting to ADB any grievances or allegations of corrupt practices arising out of the project and project activities. For each contract, the webpage shall include information on among others the list of participating bidders, name of the winning bidder, basic details on bidding procedures adopted, amount of contract awarded, and the list of goods/services, including consulting services, procured.

Latest procurement plan is amended from time to time. Latest version is available in the web for reference.

All procurement of goods and works will be undertaken in accordance with ADB's Procurement Guidelines (2015, as amended from time to time). For Cambodia, Lao PDR, and Myanmar ICB procedures will be used for goods valued at $1,000,000 or above; national competitive bidding (NCB) procedures will be used for goods valued below $1,000,000 but above $100,000; and shopping procedures will be used for goods valued at $100,000 and below. For Viet Nam, ICB procedures will be used for goods valued at $5,000,000 or above; NCB for goods valued below this amount but above $100,000; and shopping procedures will apply for goods valued at $100,000 and below. Some works packages are also included.