To develop an initial costing framework for IHR implementation, we sought case-study countries that could provide examples of field-tested strategies and practices in the 8 IHR core capacities and at points of entry, along with associated costs. On the basis of geographic proximity, recent responses to emerging infectious diseases of public health significance, economic development levels, and accessibility of financial and policy information, we identified 6 case-study countries in Southeast Asia: 1 low-income (Cambodia), 3 lower-middle income (Lao People’s Democratic Republic, Vietnam, and Timor-Leste), and 2 upper-middle income (Malaysia and Thailand) (9). These 6 countries fall into the SEARO and WPRO areas, which share the Asia Pacific Strategy for Emerging Diseases capacity-building strategy (8).

The 2010 WHO IHR Monitoring Framework identified 20 country-level indicators that states parties could use to assess IHR core capacity development (Table 1). The framework described levels of capability that could be used to evaluate progress toward each indicator, categorizing capabilities as prerequisites/foundational (level <1), inputs and processes (level 1), outputs and outcomes (level 2), and additional (level 3). Framework guidance specified that for all indicators to meet IHR requirements, countries must successfully demonstrate the attributes at levels 1 and 2.

For each country-level indicator, we identified specific activities and resources that could operationally achieve levels 1 and 2 attributes. Identification involved a 2-step process: 1) determining whether a technical standard exists for achieving each country-level indicator and 2) mapping activities and strategies among the case-study countries to the IHR Monitoring Framework.

To identify standards for building and sustaining the 8 core capacities, we reviewed guidance published by WHO and its regional offices, accrediting and professional organizations, and the US Centers for Disease Control and Prevention; consensus recommendations developed by expert working groups; and peer-reviewed publications, supplemented by additional input from subject matter experts in relevant disciplines.

To describe capabilities, activities, tools, and processes identified by decision makers in each case-study country as relevant to IHR core capacities, we reviewed published and unpublished government documents (e.g., legislation; regulations; national strategies; operational and programmatic guidance; training materials; self-assessments; proposed and enacted budgets; and plans for developing, strengthening, or maintaining IHR core capacities, pandemic preparedness, public health or emergency medical preparedness, indicator- and event-based surveillance, and laboratory systems) and materials prepared with or for development partners, technical partners, and nongovernmental stakeholders in each country. We supplemented the literature review through interviews with governmental and nongovernmental stakeholders in case-study countries. To determine requirements for diagnostic testing capabilities, we derived a priority disease list comprised of the endemic, epidemic-prone, and emerging infectious diseases specifically cited as always notifiable by the IHR (2005) Annex 2 reporting algorithm plus those appearing on >3 case-study country priority disease lists.

We mapped the activities and strategies identified through the reviews of technical guidance and case-study country activities to specific country-level indicators in the IHR Monitoring Framework, creating an operating core capacities matrix. To identify the practices and attributes common to some or all case-study countries for each core capacity, we compared these activities and strategies, distilling the strategies and practices into a representative Southeast Asian country, hereafter referred to as Country X, that has achieved levels 1 and 2 under each country-level indicator. Where no clear consensus emerged on strategies or practices, we selected the national approach that most closely resembled international or regional technical standards.

For each activity or capability mapped to a specific country-level indicator in the Country X core capacities matrix, we extrapolated requirements for physical infrastructure (facilities, equipment, utilities), human capabilities (workforce, training, skills, and knowledge), and tools and processes (e.g., diagnostic platforms, materials, reagents, quality control and assurance, reporting systems), building on the foundations of existing public health surveillance costing platforms, such as the Integrated Disease Surveillance and Response SurvCost tool (10). Because of the integrated nature of the IHR core capacities, some physical infrastructure, human resources, and tools and processes might contribute to multiple core capacities. We sought to prevent overlap by including such elements only 1 time, under the most immediately relevant indicator.

To develop a preliminary cost estimate for developing and sustaining such infrastructure, human capabilities, and tools and process, we used the following: 1) costs calculated by case-study country government actors for procurement or national budgets; 2) estimates derived with or for international partners; 3) the WHO CHOICE (CHOosing Interventions that are Cost Effective) database as a source of average salaries, per diem and travel compensation, physical infrastructure, and tradables specific to the subregions of SEARO B and WPRO B, into which the case-study countries fall; and 4) commercial price lists and supply schedules. Because the WHO CHOICE dataset expresses average costs in 2005 international dollars (defined as equivalent to $US in 2005 purchasing power parity), we likewise included or adjusted all costs in 2005 $US. We did not attempt to distinguish between the contributions of public, private, or international actors in mapping the surveillance, response, and laboratory systems for Country X. We thus assumed that the total costs of developing and sustaining each activity or capacity would be the same regardless of the payer. We did not attempt to calculate tariffs or other additional fees specific to each country.

The Country X template represents a composite of demographic, political, and geographic attributes of 6 low- to middle-income case-study countries in 2 WHO sub-regions (SEARO B and WPRO B). All estimates for Country X assume a population of 60 million persons; 64 provinces with 600 functional districts; and 6 designated points of entry with a Ministry of Health responsible for public health surveillance, response, and laboratory capabilities at the national, provincial, district, and community levels (Figure 1).

Among the case-study countries, national strategies for public health surveillance depend heavily on facility-based surveillance. The reliability and timeliness of facilities-based reporting depend on population access to basic health services with trained health workers at peripheral, intermediate, and central levels. Such services are an absolute prerequisite to IHR implementation but are not explicitly included in the IHR (2005) or associated guidance. Any estimates for costs of public health surveillance and response developed through the framework described here should therefore be considered additional to the costs of developing and sustaining adequate essential health services.

Country-level indicators focus on adoption of budgetary and regulatory frameworks to support IHR implementation. We identified only 1 input with cost implications—support for legal expertise (domestic or external consultants) to review and, as needed, revise national public health laws, estimated at $75,000 (in 2005 $US)—which was based on past consulting costs for revising national regulations with regard to avian and human influenza.

IHR coordination, communications, and advocacy require designation of an IHR National Focal Point and mechanisms to identify, convene, and coordinate stakeholders in public health surveillance and response across sectors. Inputs include information and communications technologies equipment and services as well as office infrastructure, transportation, and salary support for the individual or office serving as National Focal Points (Technical Appendix Table 1).

The IHR Monitoring Framework specifies that this core capacity encompasses indicator-based surveillance (the routine reporting of diseases or syndromes that meet specific case definitions) and event-based surveillance (the rapid detection and reporting of unusual or unexpected disease patterns, deaths, and exposure risks) (Figure 2; Technical Appendix Table 2). All case-study countries conduct national indicator-based surveillance for priority diseases and have developed strategies for combining routine surveillance data with reports from other sources to provide early warning of emerging public health events. The resources for detecting, reporting, and managing cases of priority diseases and unusual events overlap substantially in the Country X template, particularly at the community level.

For Country X, we developed a template for surveillance staffing structure based on a combination of health systems structure and population. We did not attempt to prorate the share of office space, utilities, transportation, etc., dedicated to surveillance for epidemic-prone or emerging infections versus other goals (such as tracking nonommunicable conditions or high-risk behavior).

Country X template inputs for response include a functional, dedicated command and control center with room and information and communications technology equipment and services to accommodate up to 40 personnel during an event (Technical Appendix Table 3). Other inputs include materials, supplementary compensation, training, and travel allowances for 2 trained, 5-member multidisciplinary rapid response teams per province, plus 2 central rapid response teams, to investigate and respond to at least 1 public health event per year, with logistical and risk communications support from the provincial level. Inputs also include development and dissemination of guidance for infection control and case management, related training, and systems for isolating and transporting potentially infectious patients.

The inputs for the Country X preparedness template encompass development, planning, and testing of a national public health emergency response plan (Technical Appendix Table 4). This template is based on a comprehensive national risk assessment and on establishment of a national stockpile of materials to respond to priority events.

Inputs for risk communication include the development, printing, and dissemination of a national risk communications plan (Technical Appendix Table 5). These activities are supported by annual training workshops and purchase of broadcast and print media at the peripheral, intermediate, and central levels.

The inputs for human resources in Country X include resources for developing a coordinated national strategy for public health workforce development (Technical Appendix Table 6). The inputs also include resources for fully supporting field epidemiology training (including travel support for field investigations) for as many as 16 trainees per year.

For diagnostic testing capabilities, we identified the testing platforms, materials and reagents, and specimen collection and referral systems necessary to support detection and confirmatory testing of the Country X priority diseases as appropriate at each level of a tiered, integrated health system. Technical Appendix Table 7 represents costs only of infrastructure and human capabilities associated with laboratory capacity.

The inputs for the Country X template include a health office at each designated point of entry (Technical Appendix Table 8). Each office is staffed by 4-person multidisciplinary public health response teams trained and equipped to respond to medical emergencies.