Lessons learnt from implementation of the International Health Regulations: a systematic review

Bull World Health Organ 2018;96:110–121E | doi: http://dx.doi.org/10.2471/BLT.16.189100 Systematic reviews 110 Lessons learnt from implementation of the International Health Regulations: a systematic review Amitabh B Suthar,a Lisa G Allen,b Sara Cifuentes,c Christopher Dyed & Jason M Nagatae Introduction While bi- and multilateral communication and collaboration are the foundation for global control of infectious disease epidemics, they are strengthened by the International Health Regulations (IHR). First introduced in 1969, IHR is global legislation requiring countries to link and coordinate specific actions.1 These regulations were originally designed to control cholera, plague, yellow fever, smallpox, relapsing fever and typhus. Given the need to expand the scope to include new epidemics and to improve global coordination, the regulations were revised in 2005, as IHR (2005).2 One of the key changes was the requirement for countries to notify the World Health Organization (WHO) of all events that may constitute a public health emergency of international concern and to respond to requests for verification of information about these events.2 Since IHR (2005) was adopted by WHO States’ Parties, several outbreaks, epidemics and pandemics have been declared public health emergencies of international concern: the H1N1 pan- demic influenza in 2009, wild poliovirus in 2014, Ebola virus disease in 2014, and Zika virus and increases in neurological disorders and neonatal malformations in 2016.3–6 IHR (2005) also requires all countries to develop, strength- en and maintain eight core public health capacities.2,7 These core capacities cover: (i) national legislation, policy and financing; (ii) coordination and national focal point communications; (iii) surveillance; (iv) response; (v) preparedness; (vi) risk communication; (vii) human resources; and (viii) laboratory.8 Given varying levels of health and socioeconomic development across countries, there have been challenges in implementing these requirements. By the original deadline of June 2012, only 42 (22%) of the 192 WHO Member States had met the core capacity requirements.9 Yet substantial progress has been made in some areas. These include establishing a 24-hour presence of a national focal point to communicate with all relevant sec- tors within government, all national stakeholders and WHO; increased transparency in reporting events; using early warning systems more systematically; and better communication and collaboration between the animal and human health sectors. Nevertheless, by the end of 2015, 127 of the 192 countries had not meet all IHR (2005) core capacity requirements.9,10 Although IHR (2005) describes what must be achieved by countries, there is limited knowledge on how countries should proceed in achieving the core capacities. To fill this gap and accelerate implementation of IHR (2005), the World Health Assembly in 2015 identified a need to evaluate and share the lessons learnt from countries that have implemented IHR (2005).11 While country exchanges and regional meetings are one mechanism to achieve this, we systematically evaluated published literature and reports for lessons learnt from national experience in implementing IHR (2005). Methods This systematic review was conducted in accordance with En- hancing Transparency in Reporting the Synthesis of Qualitative Research guidelines, using a predefined protocol (International Prospective Register of Systematic Reviews identification num- ber: CRD42016038719).12,13 We systematically searched the PubMed®, Embase®, Global Health, Scopus and WHO Global Objective To respond to the World Health Assembly call for dissemination of lessons learnt from countries that have begun implementing the International Health Regulations, 2005 revision; IHR (2005). Methods In November 2015, we conducted a systematic search of the following online databases and sources: PubMed®, Embase®, Global Health, Scopus, World Health Organization (WHO) Global Index Medicus, WHO Bulletin on IHR Implementation and the International Society for Disease Surveillance. We included identified studies and reports summarizing national experience in implementing any of the IHR (2005) core capacities or their components. We excluded studies that were theoretical or referred to IHR (1969). Qualitative systematic review methodology, including meta-ethnography, was used for qualitative synthesis. Findings We analysed 51 articles from 77 countries representing all WHO Regions. The meta-syntheses identified a total of 44 lessons learnt across the eight core capacities of IHR (2005). Major themes included the need to mobilize and sustain political commitment; to adapt global requirements based on local sociocultural, epidemiological, health system and economic contexts; and to conduct baseline and follow-up assessments to monitor the status of IHR (2005) implementation. Conclusion Although experiences of IHR (2005) implementation covered a wide global range, more documentation from Africa and Eastern Europe is needed. We did not find specific areas of weakness in monitoring IHR (2005); sustained monitoring of all core capacities is required to ensure effective systems. These lessons learnt could be adapted by countries in the process of meeting IHR (2005) requirements. a South African Centre for Epidemiological Modelling and Analysis, University of Stellenbosch, Private Bag X1, Matieland, Stellenbosch, 7602, South Africa. b TMF Health Quality Institute, Austin, United States of America (USA). c Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, USA. d Department of Strategy, Policy and Information, World Health Organization, Geneva, Switzerland. e Department of Pediatrics, University of California San Francisco, San Francisco, USA. Correspondence to Amitabh B. Suthar (email: amitabh.suthar@gmail.com). (Submitted: 28 November 2016 – Revised version received: 26 October 2017 – Accepted: 14 November 2017 – Published online: 11 December 2017 ) S stematic reviews Bull World Health Organ 2018;96:110–121E| doi: http://dx.doi.org/10.2471/BLT.16.189100 111 Systematic reviews International Health Regulations implementationAmitabh B Suthar et al. Index Medicus databases without any limitations of language, publication type or date on 13 November 2015. We searched all databases for the terms “IHR” or “International Health Regulations” to ensure we captured articles focusing specifically on IHR implementation. We did not search additional terms for the core capacities since this would decrease the number of results from the databases and potentially decrease the sensitivity of the search strategy. We also searched updates from the WHO bulletin on IHR implementation and abstracts from the International Society for Disease Surveil- lance annual conferences.14,15 Studies were included when they summarized national experience in implementing any of the IHR (2005) core capacities or their com- ponents (Box 1).8 We excluded studies that referred to IHR (1969) or were theoretical and not rooted in national experience. Two authors independently screened all abstracts, articles and reports and then matched the full texts selected during screening against the inclusion criteria. The reference lists of relevant articles and reviews were also searched for additional studies and reports. Articles meeting the inclusion criteria were included in the review. Three authors completed the data extraction using standardized extraction tables. Two authors independently read and assessed the quality of included studies using the Critical Appraisal Skills Pro- gramme qualitative research checklist.16 Disagreements in quality assessment between reviewers were resolved through discussion. In case new insights, ground- ed in data, might be generated in studies classified as low methodological quality, no studies were excluded on the basis of the quality assessment.17,18 We used the Cochrane qualitative systematic review method, including me- ta-ethnography, to synthesize qualitative data.17,19–22 Meta-ethnography involved three steps: (i) reciprocal translational analysis (comparison); (ii) refutational synthesis (contrast); and (iii) line of argu- ment synthesis (high-level synthesis).23,24 We extracted key quotations from each study into an Excel spreadsheet (Microsoft Corporation, Redmond, United States of America) and organized these into facilitators or barriers to implementation for each component of the eight IHR core capacities.25 Each quotation was summarized into a theme. For reciprocal translation analysis, we compared similar themes from individual studies within each core capacity and synthesized lessons learnt that reflected themes from multiple studies. For refutational synthesis, we con- trasted themes between individual studies within each core capacity and noted dis- agreements. Line of argument synthesis was used to identify lessons learnt that were relevant to multiple core capacities (i.e. cross-cutting themes).24 Results Search results We identified 1075 abstracts through database searches. After removing du- plicates and screening out non-relevant abstracts, we assessed 93 full-text articles for eligibility and excluded 45. We iden- tified three abstracts from the Interna- tional Society for Disease Surveillance’s annual conferences. In total 51 articles, published from 2007 to 2015,26–77 met the eligibility criteria (Fig. 1; Table 1 and Ta- ble 2 (both available at: http://www.who. int/bulletin/volumes/96/2/16-189100). A more detailed summary of the included articles and themes identified is available from the corresponding author. Some articles reported national experience in IHR (2005) implementation in multiple countries. In total, 77 countries were represented from all WHO Regions: 23 from Western Pacific, 16 from Europe, 14 from Africa, 11 from the Americas, eight from Eastern Mediterranean and five from South-East Asia (Fig. 2). A total of 44 lessons learnt were synthesized from the eligible articles (Box 2; Box 3). Implementation of core capacities A total of 33 articles from 60 countries reported experience implementing the national legislation, policy and financing core capacity.27,29–31,34–41,44,47,50–54,56,57,59–61, 64,66,68,70–74 In Cambodia, India and Ugan- da, the need to develop basic health- system functions (e.g. expanding access to health services that are essential for treating patients and for disease surveil- lance) had to be balanced against the commitment to meeting IHR (2005) requirements.30 Some low- and middle- income countries were concerned that large inflows of external funding for IHR (2005) would create vertical programmes that could not be fully incorporated within their health systems.30 In the USA, stakeholders need to ensure coverage Box 1. Core capacities and components of the International Health Regulations (2005) Core capacity 1: National legislation, policy and financing Component 1A: National legislation and policy Component 1B: Financing Core capacity 2: Coordination and national focal point communications Component 2A: IHR coordination, communication and advocacy Core capacity 3: Surveillance Component 3A: Indicator-based surveillance Component 3B: Event-based surveillance Core capacity 4: Response Component 4A: Rapid response capacity Component 4B: Case management Component 4C: Infection control Component 4D: Disinfection, decontamination and vector control Core capacity 5: Preparedness Component 5A: Public health emergency preparedness and response Component 5B: Risk and resource management for IHR preparedness Core capacity 6: Risk communication Component 6A: Policy and procedures for public communications Core capacity 7: Human resources Component 7A: Human resource capacity Core capacity 8: Laboratory Component 8A: Policy and coordination of laboratory services Component 8B: Laboratory diagnostic and confirmation capacity Component 8C: Laboratory biosafety and laboratory biosecurity (biorisk management) Component 8D: Laboratory-based surveillance IHR: International Health Regulations. Source: International Health Regulations (2005).7 Bull World Health Organ 2018;96:110–121E| doi: http://dx.doi.org/10.2471/BLT.16.189100112 Systematic reviews International Health Regulations implementation Amitabh B Suthar et al. and enforcement of legislation within private health-care facilities, where most citizens receive health services.34 In Brazil, creation of legislation, policy and guidelines was found to be insufficient without training and mechanisms to enforce implementation of IHR (2005).51 Experience implementing the co- ordination and communications capac- ity was reported in 33 articles from 51 countries.26–31,33,36,38–43,46–48,50–52,56,57, 59,61,63, 64,66,68,70,71,73,76,77 In Cambodia, India and Uganda, failing to coordinate through the national focal point led to duplication of surveillance strengthening efforts.30 In Papua New Guinea, capacity to govern is variable at the subnational level, and the reach of the national focal point needs to be expanded to local partners beyond the health sector.33 Forty articles from 63 countries re- ported experience implementing the sur- veillance core capacity.26–43,45–47,50,51,53–55,57, 59,60,62,63,65,67,68,71,73–76 In the European Union, researchers identified a need for manuals of surveillance standards, guidelines, case definitions and protocols for reporting and disease notification.38,39 Reports from France, Iceland Indonesia and Madagascar noted the complemen- tary nature of early warning systems, event-based surveillance and syndromic surveillance for detecting different types of epidemics.55,63,75 Experience in Papua New Guinea reinforced the need for periodic evaluations of syndromic and event-based surveillance systems.33 A study from the Pacific Islands identified a need to adapt surveillance information systems to the local context.59 Experience implementing the re- sponse core capacity was reported by 27 ar- ticles from 47 countries.26–36,39,42,43,45,46,51–54, 56,60,62,68,71,73,74 Experience from the Repub- lic of Moldova reinforced the importance of interdisciplinary rapid response teams (e.g. epidemiologists, microbiologists, hygienists, environmental health profes- sionals and laboratory technicians).36 In Uganda, a command centre was created to house the rapid response team and to receive, evaluate and distribute informa- tion.29 Experience from Chile indicated the importance of having infection con- trol committees composed of staff from different levels of the health system (e.g. hospital, provincial and national).26 A report from the United Kingdom of Great Britain and Northern Ireland and its ter- ritories emphasized the need for response plans to be reviewed and updated regu- larly to respond to all hazards: zoonotic, food safety, chemical, radionuclear and antimicrobial resistance threats.39 Thirteen articles from 37 countries reported experience implementing the preparedness core capacity.26,27,29,32,34–36,40,45, 49,50,52,56,73,74,76 In the United Republic of Tan- zania, failure to create specific budget lines for public health preparedness hampered preparedness planning.27 Experience from Asia during the H1N1 influenza pandemic found that, in addition to national plans, regions may need to develop multicountry preparedness plans focused on real-time information sharing.50 A total of 23 articles from 36 countries reported on implementing the risk commu- nication core capacity.26–29,33,35,36,42,45,46,50–53, 55,57,59,68,71,73,76 Experience from Papua New Guinea and the USA found that regular interactions with the media helped to build relationships, trust and functioning communication streams for use in times of emergency.33,42 In the Republic of Moldova and sub-Saharan Africa, bi-directional communication streams allowed central authorities to communicate with subna- tional levels to raise awareness, receive information from subnational authorities, and ultimately conduct investigations on disease epidemics.36 A total of 37 articles from 49 coun- tries reported experience implement- ing the human resources core capac- ity.26,27,29–31,33–39,41,42,44–46,49–54,56–59,61–64,68,71–74 Experience from Cambodia, India, Ugan- da and the United Kingdom indicated that traditional curricula, competencies and training did not prepare the workforce to implement IHR (2005) and that additional knowledge transfer and skill-building is needed to ensure reporting and data use at subnational levels.30,39 The sociocultural context influenced learning preferences; for example, in Morocco face-to-face learning was preferred, while in India and the United Kingdom electronic learning Fig. 1. Flowchart on the selection of articles for the systematic review on the implementation of the International Heath Regulations (2005) 1075 abstracts identified through database searches 93 full-text articles assessed for eligibility 51 articles included in qualitative synthesis IHR (2005) core capacities covered by included articles: • 33 on national legislation, policy and financing • 22 on coordination & communications • 40 on surveillance • 27 on response • 13 on preparedness • 23 on risk communication • 37 on human resources • 26 on laboratory 444 abstracts screened 48 articles eligible 631 duplicates removed 351 abstracts not relevant 3 conference abstracts identified 45 articles excluded because they did not summarize national experience in implementing IHR (2005) IHR (2005): International Health Regulations, 2005 revision. Notes: Some of the included articles did not report on all eight core capacities of the IHR (2005). The three abstracts were from annual conferences of the International Society for Disease Surveillance. Bull World Health Organ 2018;96:110–121E| doi: http://dx.doi.org/10.2471/BLT.16.189100 113 Systematic reviews International Health Regulations implementationAmitabh B Suthar et al. was preferred.39,45,61 In China, Morocco, South Africa and the United Kingdom, interactive and skill-building sessions were preferred over static knowledge transfer.41,61,74 Settings that had high staff turnover (e.g. rural areas, those with armed conflicts) faced staff shortages and required unique mechanisms for con- tinual retraining.31,39,59,63 Experience implementing the labora- tory core capacity was reported in 26 ar- ticles from 44 countries.26–31,34,36,39–42,45,46,50, 52–54,56,57,62,68,71,73,77 Studies in Afghanistan, Uganda and the United Kingdom identi- fied a need to develop laboratory capacity for basic tasks such as collection, trans- portation and analysis of specimens.31,39,73 Several sub-Saharan counties needed lab- oratory accreditation systems, supported by training and mentoring, and external quality assurance systems in place, as well as laboratory information systems that directly influence public health action.54 Cross-cutting themes We identified five global lessons learnt that related to multiple IHR (2005) core capacities (Box 2). Some major cross-cutting themes included the need for mobilizing and sustaining political commitment; for adapting global re- quirements based on the local sociocul- tural, epidemiological, health system and economic contexts; and for conducting baseline and follow-up assessments to monitor IHR (2005) status. Discussion We found substantial documentation of lessons learnt from implementing IHR (2005) core capacities globally. Although many factors affected implementation in a country, the structure of the health system, sociocultural factors, economic status and type of governance, we were able to extract some common themes. We found few gaps in implementation in direct relation to the IHR (2005) core ca- pacities. Nonetheless, additional research could be useful in evaluating countries’ core capacity performance against actual disease epidemics. Specifically, we did not identify any documentation evaluating IHR (2005) core capacity development with national performance in prevent- ing, detecting and responding to disease epidemics. This type of evaluation could provide useful data for future revisions of the IHR. Moreover, defining fundamental data needs for new treatments and vac- cines could help develop national research F ig . 2 . Co un tr y l oc at io n of st ud ie s a nd re po rt s i nc lu de d in th e sy st em at ic re vi ew o f i m pl em en ta tio n of th e In te rn at io na l H ea th R eg ul at io ns (2 00 5) , b y W or ld H ea lth O rg an iz at io n Re gi on Re gio n o f t he A m eri ca s Eu rop ea n R eg ion Ea ste rn M ed ite rra ne an Re gio n Af ric an Re gio n So ut h- Ea st As ia Re gio n W es ter n P ac ific Re gio n Co un tri es re pr es en ted in st ud ies /re po rts 0 87 5 17 50 3 5 00 km N Bull World Health Organ 2018;96:110–121E| doi: http://dx.doi.org/10.2471/BLT.16.189100114 Systematic reviews International Health Regulations implementation Amitabh B Suthar et al. capacity to shorten the development window during future disease epidemics. Finally, additional documentation of ex- perience from Eastern Europe and Africa could help fill knowledge gaps. Countries had different national health plans outlining how to organize their systems and strategies for manag- ing threats and hazards.78 National plans typically outlined how health priorities will be managed and linked to programme- specific strategic plans, such as those for primary health care, maternal and child health, human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS). To avoid having only vertical programmes, countries will have to decide how to integrate IHR (2005) core capac- ity development within existing strategic plans, such as those for the health work- force or laboratory systems. Integration of IHR (2005) into national legislation is also required. To achieve this, WHO proposed that countries need to consider how the IHR (2005) are to be implemented based on their national legal and governance con- text; to assess existing legislation for IHR (2005) implementation; to revise existing legislation or adopt new legislation; and to enforce nationally adapted legislation.69,79 Most countries reported some experience in implementing commu- nicable disease surveillance as part of IHR (2005).80 Although core capacity requirements for surveillance are the same for all countries, the means to achieve them differed. For example, real-time systems worked well in settings with good electronic and telecommuni- cations infrastructure, while delays were common in settings with more limited infrastructure.59 Such delays were acute in rural settings where health staff face logistic challenges in reporting events and may not be fully aware of the ben- Box 2. Lessons learnt synthesized from the systematic review of national implementation of the International Health Regulations (2005), organized by core capacities 1–4 Core capacity 1: National legislation, policy and financing 1. It is important to mobilize and sustain political commitment to developing the core capacities of IHR (2005) from central government, subnational levels of government, civil society and the scientific community.40,59 2. Developing appropriate policies and allocating responsibilities for the workforce is needed at both central and subnational levels of government.29,39,61 3. Legislation and policies should strive to incorporate and balance global, regional, national and subnational priorities for health security.30,31,47 4. For sustainable financing, detailed long-term national strategic plans with budget allocations should be developed in partnership between government, national stakeholders, and non-state actors (i.e. companies, high net-worth individuals and philanthropic foundations).47,52,71 5. The national health system and sociocultural context of a country will determine priorities for funding and other resource needs for IHR (2005) core capacity development, emergency response and the health workforce.64,70 6. Creating and empowering a national secretariat responsible for mobilizing and securing resources from state and non-state actors can help ensure sustainable and continuous financing.39,44,47 Core capacity 2: Coordination and national focal point communications 1. Existing regional and global intergovernmental organizations can be recruited to collaborate and co-manage international epidemics.26,52,73 2. A strong programmatic structure at the national and subnational levels, including intersectoral national technical working groups, can assist with comprehensive and effective coordination.43,63,68 3. Establishing roles, responsibilities and terms of reference of national focal points within national legislation, and disseminating information inside government, to national stakeholders, and to WHO, improves coordination and communication.27,51,74 4. Adequately resourced communication channels and standard operating procedures, from the subnational to the inter-governmental level, facilitate the timely transmission and retrieval of information.26,29,57,73 Core capacity 3: Surveillance 1. It is important to create and empower a national government entity to coordinate disease surveillance and control efforts.26,27 2. Strategic plans for disease surveillance at both the national and subnational levels can enable long-term sustainability of these efforts.30,47 3. Key communicable diseases need to be categorized based on epidemiological context (e.g. endemic diseases, target for disease elimination or eradication, epidemic-prone diseases and novel diseases).26,30,60 4. Surveillance at the subnational level can be sustained by developing legislation that outlines the requirements, mechanisms (e.g. indicator- or syndromic-based surveillance7) and frequency of reporting, stratified by communicable disease category and supported by guidelines and standard operating procedures.33,38 5. Validated training tools and resources (e.g. field epidemiology training programmes) can develop capacity for collection, analysis and use of data at subnational levels.31,33,42,54,58 6. A unified and dynamic surveillance system to track alerts, updates and early warnings and response, and using technologies appropriate to the national context (e.g. electronic, open-source, internet-based, real-time, mobile phone platform), encourages appropriate information use and accurate reporting.28,33,37 7. Standardizing passive data collection, management and validation procedures across all reporting sites, and actively searching for potential surveillance intelligence through local communication channels (e.g. community leaders, print media, internet, television), improves the usability and timeliness of data.36,55,59,63 Core capacity 4: Response 1. Defining criteria for an emergency public health event (e.g. seriousness, impact, unexpectedness, risk for international spread, risk for trade or travel) assists with the initiation of an appropriate and timely response.36,39 2. Establishing roles, responsibilities and terms of reference for a multidisciplinary response unit supports coordination of public health emergency responses at the national and subnational levels.26,27,36,53 3. Including national and international stakeholders in the development of guidelines for rapid and emergency response facilitates wide technical ownership and financial support.39,46,52 4. Designing and resourcing health facilities to minimize nosocomial infection transmission improves the efficacy of response without encouraging further spread (e.g. building isolation rooms, ensuring adequate ventilation, providing personal protective equipment).26,73 Bull World Health Organ 2018;96:110–121E| doi: http://dx.doi.org/10.2471/BLT.16.189100 115 Systematic reviews International Health Regulations implementationAmitabh B Suthar et al. efits of reporting events.33 Nevertheless, minimizing delays in discovering and declaring disease outbreaks remains a global priority.81 Prospectively, verti- cal disease surveillance systems (e.g. population-based surveys for HIV/AIDS, case reporting for malaria and cohort monitoring for tuberculosis) could be used and adapted when developing and maintaining the surveillance core capac- ity of IHR (2005).30 Although complementary in nature, the preparedness and response core capacities were often implemented inde- pendently of one another. For example, areas requiring coordination across both of these core capacities, such as case management or infection control, were not well-documented. Taking a holistic approach to IHR (2005) core capacity de- velopment could avoid these issues.26,45,52 Moreover, there were cases in which it was difficult to implement national IHR (2005) policies. For example, in the United Republic of Tanzania protocols for isolating patients with certain diseases were developed, but due to shortages of public-sector health facilities private sector hospitals had to be used during epidemics.27 This highlights the need to adapt global core capacities require- ments to locally appropriate policies and solutions. Box 3. Lessons learnt synthesized from the systematic review of national implementation of the International Health Regulations (2005), organized by core capacities 5–8 and cross-cutting themes Core capacity 5: Preparedness 1. Comprehensive national and subnational budgeted plans for preparedness of emergency public health events are needed to support timely action.26,27 2. Exercises, drills, assessments and evaluations can test capacity to implement the response plans and ensure they are adequate and operational.26,27 3. A national reserve of medicines, vaccines and laboratory supplies and reagents helps with management of public health emergencies.26,27,73 Core capacity 6: Risk communication 1. An intersectoral system for risk communication of public health emergencies, functioning at all levels of government, ensures timely action and response.33,46,59 2. Risk communication systems should be bidirectional, with linkages to national and international public health partners, to collect and disseminate information about threats.29,36,42 3. Regular and emergency information to national and international stakeholders assists in building and maintaining effective communication channels and relationships.28,45,73 4. Standard operating procedures ensure personnel are ready to investigate and communicate emerging epidemics and support preparedness for activation of early warning systems.26,42,57 5. Using a combination of media to send and receive information ensures wide access and use.33,35,46,68 Core capacity 7: Human resources 1. Identifying competency gaps in the workforce ensures that training and resources are targeting the highest priority needs (e.g. epidemiology, problem-solving, management and leadership, technical expertise in pandemic and epidemic diseases).54,61,74 2. Selecting appropriate media for developing competencies based on health system context and social and cultural preferences can increase the efficacy of training.38,45,61 3. Establishing workforce oversight mechanisms for long-term maintenance of current and future needs assists with sustainability of individual training efforts.30,41,44 4. Nationally agreed strategies to recruit, train and retain health workforce can help support IHR (2005) competency development at all levels of the health system.54,56,64 Core capacity 8: Laboratory 1. It is important to create a governmental entity at the national level to coordinate national strategic plans for laboratory response and develop national standards, guidelines and operating procedures for laboratory surveillance at national and subnational levels.26,34,52,54,73 2. Regional and global reference laboratories can be helpful when developing laboratory surveillance networks.27,41,42 3. Validated criteria and mechanisms to accredit laboratories for core surveillance tasks help ensure high-quality testing.31,54,73 4. Laboratory training, routine assessments and feedback, and quality assurance systems can help improve surveillance capacity and function of national and subnational laboratories.29,54 5. Bidirectional flows of data, specimens and communication between national and subnational levels of government improve laboratory system effectiveness and adequate public health investigation.27,29 6. Specific policies, strategies, regulations and standard operating procedures for high-containment biosafety laboratories help ensure the safety and efficacy of laboratory testing.29,52,73 Cross-cutting themes 1. Conducting a baseline needs assessment can help to identify the status of a country’s health system and actions needed to meet IHR (2005) requirements.27,54,73 2. Ensuring flexible systems can improve response to known epidemics and detection of new threats.29,70,74 3. A country’s’ sociocultural, epidemiological, health system and economic context and priorities will guide national implementation of IHR (2005) core capacities.59,64,68 4. Although early warning systems are part of core capacity in surveillance, they also affect coordination, risk communication and response for new epidemics.36,46 5. Having a skilled workforce in place, from frontline staff to senior management, is important for ensuring sustainable expertise, implementation and commitment.29,30,39,61 IHR (2005): International Health Regulations, 2005 revision: WHO: World Health Organization. Notes: Framework for the analysis was based on the eight core capacities of the International Health Regulations (2005).7 Bull World Health Organ 2018;96:110–121E| doi: http://dx.doi.org/10.2471/BLT.16.189100116 Systematic reviews International Health Regulations implementation Amitabh B Suthar et al. Risk communication focuses pri- marily on effective communication strategies during disease epidemics. Some of the articles we identified primarily discussed communication systems.33,46,59 For example, while many countries documented positive experi- ence with internet-based communica- tion strategies, inconsistent access to electricity and telecommunications in the United Republic of Tanzania made this challenging.27 More documentation of risk communication lessons learnt during epidemics are needed. For ex- ample, there was delayed notification and underreporting of cases from the national to international level during the severe acute respiratory syndrome epidemic in China in 2002.16 This delay may have contributed to preventable transmission of the virus and galva- nized international interest in revising IHR(2005) to ensure transparency and timeliness of communication during disease epidemics.82,83 The World Health Assembly recently approved the Global strategy on human resources for health: workforce 2030.84 De- velopment of human resources required by IHR (2005) could be included within national strategies for human resource development. Initial quantification of needs could be completed through the use of WHO recommended tools such as the Workload Indicators of Staffing Need.85 Most health workforce strategies are long-term and require development and revision of curricula, competencies, professional continuing education and licensing. Although international sup- port plays a role in training local staff, Indonesia and South Africa, among others, noted that this mechanism was often resource-intensive and unsustain- able.41,42,44 Moreover, given that front-line health staff may be resistant to additional administrative duties and responsibilities without increased remuneration, it is es- sential to reduce redundancies in roles and responsibilities across different disease programmes.30 Laboratory networks are an essen- tial part of national and regional health systems. Global laboratory networks are in place for polio, immunization pro- grammes and influenza.86–88 It could be worthwhile to adapt and integrate these existing networks to meet IHR (2005) requirements. The issue of limited ca- pacity to develop laboratory infrastruc- ture in rural areas was raised.39 In these settings, disease-specific point-of-care assays may be needed, even if they do not contribute to overall strengthening of the laboratory system. Decentralized laboratory assays that contribute to control of multiple diseases (e.g. nucleic acid amplification that could be used for HIV/AIDS, tuberculosis, viral hepatitis, novel influenza strains and Ebola virus disease), rather than disease-specific as- says, may be a better way to strengthen laboratory systems.89 Given the many priorities in devel- opment, and limited national budgets to achieve them, external funding opportu- nities often help mobilize political com- mitment and national action. Experience from South Africa suggested that while external funding sources can be inflex- ible and unsustainable within national governance frameworks, such funding could create momentum in generating do- mestic financing and accelerate progress in implementing IHR (2005).41 Therefore, identifying adequate funding is the first step to developing, strengthening and maintaining national IHR (2005) core capacities. Global eradication of polio and global elimination of HIV/AIDS, tuberculosis and malaria were all costed and have been successful in mobilizing political commitment.90–93 Estimating the global and national costs of meeting IHR (2005) core capacities could also help in identifying external funding sources. Vari- ous frameworks and tools are available to cost IHR core capacity development.94,95 Depending on the setting and context, the World Bank, the International Mon- etary Fund, regional development banks, bilateral partners and non-state actors (i.e. companies, high net-worth individuals and philanthropic foundations) could all make substantial contributions towards advancing global implementation of IHR (2005).96–101 Along with financial and technical support, additional international mea- sures could help accelerate IHR (2005) core capacity development. For example, since past disease epidemics affected regional and global economic growth, economic issues are relevant.102,103 Al- lowing countries that meet IHR (2005) core capacity requirements to participate in regional and global trade agreements, or have access to grants or low-interest loans through bilateral partnerships or international financing institutions, could help mobilize political commitment and action. Conversely, if there remain per- sistent challenges in meeting the agreed IHR (2005) core capacity deadlines, trade tariffs, sanctions or embargoes might be needed to ensure countries collaborate fully in sustaining global health security. These different measures could also be used during disease epidemics in re- sponse to countries’ compliance or lack of compliance with IHR (2005) require- ments. This could help, for example, accelerate the timeliness of providing essential surveillance data to the global health community. This would represent a shift in current enforcement of IHR (2005) core capacity development that may require discussion and consensus outside of the health sector.104 Regardless of whether macroeconomic measures are implicated with IHR (2005), failure to implement IHR (2005) core capacities could adversely affect the international image of a country and also increase its susceptibility to economic losses due to disease epidemics. This study has several limitations. We focused only on IHR (2005) core capacities and not on the core capabilities of points of entry, zoonotic events, food safety, chemical events and radiation emergencies.105 Future studies should evaluate these additional aspects of IHR (2005). The databases we used only have the capacity to search the titles and ab- stracts of articles and may have missed articles that only mentioned IHR-related keywords in the full text. Using databases that have the capacity to search the full text may identify additional studies.106 There is little consensus on the use of quality appraisal in qualitative meta- ethnography and we therefore did not exclude any qualitative studies based on quality rating.18 In addition, given the limited availability of formal qualitative research, we included all documenta- tion related to IHR (2005) irrespective of study design. We relied on publicly available documentation from countries; some countries or institutions may not have published their experiences in implementing IHR (2005) due to com- peting priorities, limited capacity or lack of awareness on the importance of shar- ing their experience. After completion of this systematic review, Joint External Evaluation guidance became publicly available.107 Their mission reports pro- vide valuable information that should be included in updates to this review.108 Furthermore, annual submissions on IHR (2005) from Member States to the World Health Assembly likely contain relevant information, but are not publicly available. Bull World Health Organ 2018;96:110–121E| doi: http://dx.doi.org/10.2471/BLT.16.189100 117 Systematic reviews International Health Regulations implementationAmitabh B Suthar et al. Despite considerable progress, countries that are yet to implement IHR (2005) core capacities may have insuf- ficient human and financial resources to meet their obligations in the near future. Recent global epidemics have galvanized high-level political commit- ment towards ensuring global health security. We can leverage this com- mitment by mobilizing resources and securing wider collaboration to apply the lessons outlined here and acceler- ate the development of IHR (2005) core capacities globally. Acknowledgements JMN is also affiliated with Department of Paediatrics, Stanford University School of Medicine, Stanford, USA. Competing interests: None declared. صخلم ةيجهنم ةعجارم :ةيلودلا ةيحصلا ةيميظنتلا حئاوللا ذيفنت نم ةدافتسلما سوردلا شرن لجأ نم ةيلماعلا ةحصلا ةيعجم ءادن لىإ ةباجتسلاا ضرغلا ةيميظنتلا حئاوللا ذيفنت في تأدب يتلا نادلبلا نم ةدافتسلما سوردلا ةيلودلا ةيحصلا ةيميظنتلا حئاوللا ؛2005 ةعجارم ،ةيلودلا ةيحصلا .)2005( ماعل ةرداصلا ثحب ءارجإب 2015 ماع نم نياثلا نيشرت/برمفون في انمق ةقيرطلا رداصلماو تنترنلإا ةكبش لىع ةدجاوتلما تانايبلا دعاوقل يجهنم و ،Global Healthو ،Embase® و ،PubMed® :ةيلاتلا ،ةيلماعلا ةحصلا ةمظنلم عباتلا يلماعلا يبطلا سرهفلاو ،Scopus ةيحصلا ةيميظنتلا حئاوللا ذيفنت نأشب ةيلماعلا ةحصلا ةمظنم ةلمجو تاساردلا ينمضتب انمقو .ضارملأا ةبقارلم ليودلا عمتجلماو ،ةيلودلا نم يأ ذيفنت في ةينطولا ةبرجتلا صخلت يتلا ةددحلما ريراقتلاو )2005 ماعل( ةيلودلا ةيحصلا ةيميظنتلا حئاولل ةيساسلأا تايناكملإا لىإ يرشت يتلا وأ ةيضاترفلاا تاساردلا داعبتساب انمقو .اتهانوكم وأ مادختسا مت دقو .)1969 ماعل( ةيلودلا ةيحصلا ةيميظنتلا حئاوللا ثاترلل ةيعيمجتلا ةساردلا كلذ في ماب ،ةيعونلا ةيجهنلما ةعجارلما جنه .يعونلا جهنلا نيوكتل يقرعلا قطانلما عيجم لثتم اًدلب 77 نم ةرداص ةلاقم 51 ليلحتب انمق جئاتنلا ديدحتب يعيمجتلا نيوكتلا ماقو .ةيلماعلا ةحصلا ةمظنم ةطلسل ةعضالخا حئاولل ةينماثلا ةيساسلأا تايناكملإا برع اًدافتسم اًسرد 44 لياجمإ تاعوضولما تلمتشاو .)2005 ماعل( ةيلودلا ةيحصلا ةيميظنتلا تابلطتلما ةمءاولم سيايسلا مازتللاا معدو دشح لىإ ةجالحا لىع ةيربكلا ماظنلاو ،ةيئابولاو ،ةيفاقثلاو ةيعماتجلاا تاقايسلا لىع ًءانب ةيلماعلا ةبقارلم ةعباتلماو ساسلأا طلخ تماييقت ءارجإو ؛ةيداصتقلااو ،يحصلا .)2005 ماعل( ةيلودلا ةيحصلا ةيميظنتلا حئاوللا ذيفنت ةلاح ةيحصلا ةيميظنتلا حئاوللا ذيفنت براتج نأ نم مغرلاب جاتنتسلاا ةجاح كانه نإف ،اًعساو اًيلماع اًقاطن تلمش دق )2005 ماعل( ةيلودلا دجن لمو .ةيقشرلا ابوروأو ايقيرفأ نم قيثوتلا نم ديزلما ءارجإ لىإ ةيلودلا ةيحصلا ةيميظنتلا حئاوللا ةبقارم دنع ةددمح فعض رهاظم ةبولطم ةيساسلأا تايناكملإا عيملج ةمادتسلما ةبقارلما ؛)2005 ماعل( نم ةدافتسلما سوردلا هذه ةمءاوم نكمي .ةلاعف ةمظنأ نيوكت نماضل ةيحصلا ةيميظنتلا حئاوللا تابلطتم ةيبلت ةيلمع ءانثأ في نادلبلا بناج .)2005 ماعل( ةيلودلا 摘要 实施《国际卫生条例》的经验教训 ：系统性回顾 目标  为响应世界卫生大会呼吁，关注已经开始实 施 2005 年修订版《国际卫生条例》国家的经验教训。 方法 2015 年 11 月，我们对以下在线数据库和信息来 源进行了系统检索 ：PubMed®、Embase®、全球健康、 Scopus、世界卫生组织全球医学索引、世界卫生组织 关于《国际卫生条例》实施的公报和国际疾病监控学 会。我们列入了确定的研究和报告，这些研究和报告 总结了实施《国际卫生条例 (2005)》时的任一核心能 力或其组成部分的国家经验。我们排除了理论上或称 为《国际卫生条例 (1969)》的研究。包括元人种学在 内的定性系统评价方法被用于定性综合集成法。 发现 我们分析了代表所有世界卫生组织地区的 77 个 国家的 51  篇文章。综合分析确定了《国际卫生条 例 (2005)》的八项核心能力，总共获得了 44 项经验教 训。主要议题包括需要调动和维持政治承诺 ；根据当 地的社会文化、流行病学、卫生系统和经济环境调整 全球要求 ；并开展基线和后续评估，以监测《国际卫 生条例 (2005)》实施情况。 结论 虽然《国际卫生条例 (2005)》的实施经验涵盖了 较为广泛的全球范围，但仍需要来自非洲和东欧的更 多文件。我们在监测《国际卫生条例 (2005)》实施情 况时，并没有发现具体的弱点区域，需要对所有核心 能力进行持续监测，以确保有效的系统。各国在达到 《国际卫生条例 (2005)》要求的过程中可以根据这些经 验教训进行调整。 Résumé Leçons tirées de la mise en œuvre du Règlement sanitaire international: revue systématique Objectif Répondre à la demande de l’Assemblée mondiale de la Santé de diffuser les leçons tirées par les pays qui ont commencé à mettre en œuvre le Règlement sanitaire international, tel que révisé en 2005 – RSI (2005). Méthodes En novembre 2015, nous avons effectué une recherche systématique dans les bases de données et sources en ligne suivantes: PubMed®, Embase®, Global Health, Scopus, l’Index Medicus mondial de l’Organisation mondiale de la Santé (OMS), le bulletin de l’OMS sur la mise en œuvre du RSI et l’International Society for Disease Surveillance. Nous avons inclus des études et des rapports résumant une expérience nationale de mise en œuvre de l’une des principales capacités du RSI (2005) ou de ses composants. Nous avons exclu les études théoriques ou qui se référaient à l’édition du RSI de 1969. Nous avons utilisé une méthodologie qualitative de Bull World Health Organ 2018;96:110–121E| doi: http://dx.doi.org/10.2471/BLT.16.189100118 Systematic reviews International Health Regulations implementation Amitabh B Suthar et al. la revue systématique, et notamment une méta-éthnographie, pour réaliser une synthèse qualitative. Résultats Nous avons analysé 51 articles qui provenaient de 77 pays représentant toutes les régions de l’OMS. Les méta-synthèses ont mis en évidence 44 leçons tirées des huit principales capacités du RSI (2005). Les thèmes centraux reflétaient la nécessité de susciter et maintenir l’engagement politique; d’adapter les exigences mondiales en fonction du contexte socioculturel, épidémiologique, du système de santé et économique local; et de réaliser des évaluations de référence et de suivi pour surveiller l’avancée de la mise en œuvre du RSI (2005). Conclusion S’il est vrai que les expériences de mise en œuvre du RSI (2005) ont couvert une vaste zone géographique, une plus ample documentation provenant d’Afrique et d’Europe de l’Est est nécessaire. Nous n’avons pas trouvé de points faibles spécifiques lors du suivi du RSI (2005); un suivi permanent de l’ensemble des principales capacités est indispensable pour garantir l’efficacité des systèmes. Ces leçons tirées pourraient être adaptées par les pays engagés dans un processus de respect des exigences du RSI (2005). Резюме Практический опыт, полученный при реализации Международных медико-санитарных правил: систематический обзор Цель Откликнуться на призыв Всемирной ассамблеи здравоохранени я распрос транить информацию о практическом опыте стран, которые приступили к реализации Международных медико-санитарных правил в редакции 2005 года; ММСП (2005) (IHR (2005)). Методы В ноябре 2015 года авторы провели систематический поиск в следующих электронных базах данных и источниках: PubMed®, Embase®, Global Health, Scopus, Глобальной базе данных Global Index Medicus Всемирной организации здравоохранения (ВОЗ), Бюллетене ВОЗ, посвященном реализации ММСП, и Международном обществе по надзору за заболеваниями (International Society for Disease Surveillance). В обзор включены найденные исследования и отчеты, обобщающие национальный опыт реализации каких-либо основных возможностей ММСП (2005) или их компонентов. Исследования, которые были теоретическими или относились к ММСП (1969), были исключены из обзора. Для качественного синтеза была использована качественная методология систематического обзора, включая метаэтнографию. Результаты Авторы провели анализ 51 статьи из 77 стран, представляющих все регионы ВОЗ. При метасинтезе было выявлено в общей сложности 44 примера опыта, полученного при реализации восьми основных возможностей ММСП (2005). Основные темы включали необходимость мобилизации и поддержания стратегической приверженности, адаптации глобальных потребностей с учетом местных социокультурных, эпидемиологических, экономических условий и уровня системы здравоохранения, а также проведения исходной и последующих оценок для мониторинга хода реализации ММСП (2005). Вывод Хотя опыт реализации ММСП (2005) охватывал широкий глобальный диапазон, требуется дополнительная документация из Африки и Восточной Европы. Авторы не обнаружили определенных слабых мест при мониторинге ММСП (2005); для обеспечения эффективной работы систем требуется постоянный мониторинг всех основных возможностей. Этот полученный опыт может быть адаптирован странами при выполнении требований ММСП (2005). Resumen Las lecciones aprendidas de la implementación del Reglamento Sanitario Internacional: una revisión sistemática Objetivo Responder a la convocatoria de la Asamblea de la Organización Mundial de la Salud para difundir las lecciones aprendidas de los países que han empezado a aplicar el Reglamento Sanitario Internacional, revisión de 2005; RSI (2005). Métodos En noviembre de 2015, se realizó una búsqueda sistemática de las siguientes fuentes y bases de datos en línea: PubMed®, Embase®, Global Health, Scopus, Global Index Medicus de la Organización Mundial de la Salud (OMS), el Boletín de la OMS sobre la implementación del RSI y la Sociedad Internacional para la Vigilancia de Enfermedades. Se incluyeron estudios e informes identificados que resumen la experiencia nacional de la implementación de cualquiera de las capacidades básicas del RSI (2005) o sus componentes. Se excluyeron los estudios teóricos o que hicieran referencia al RSI (1969). Se usó una metodología cualitativa de revisión sistemática, incluida la metaetnografía, para la síntesis cualitativa. Resultados Se analizaron 51 artículos de 77 países que representan a todas las Regiones de la OMS. Las metasíntesis identificaron un total de 44 lecciones aprendidas en las ocho capacidades básicas del RSI (2005). Los temas principales incluyeron la necesidad de movilizar y mantener el compromiso político; de adaptar los requisitos globales en función de los contextos socioculturales, epidemiológicos, del sistema de salud y económicos locales; y de realizar evaluaciones iniciales y de seguimiento para supervisar el estado de la implementación del RSI (2005). Conclusión Aunque las experiencias de la implementación del RSI (2005) cubrieron un amplio rango global, hace falta más documentación de África y Europa del Este. No se hallaron áreas específicas de debilidad en la supervisión del RSI (2005). Es necesaria una supervisión sostenida de todas las capacidades básicas para asegurar unos sistemas efectivos. Estas lecciones aprendidas podrían ser adaptadas por los países en proceso de cumplir con los requisitos del RSI (2005). Bull World Health Organ 2018;96:110–121E| doi: http://dx.doi.org/10.2471/BLT.16.189100 119 Systematic reviews International Health Regulations implementationAmitabh B Suthar et al. References 1. International Health Regulations (1969). Geneva: World Health Organization; 1969. Available from: http://www.who.int/csr/ihr/ihr1969.pdf [cited 2016 Apr 29]. 2. International Health Regulations (2005). Geneva: World Health Organization; 2005. Available from: http://apps.who.int/iris/bitstre am/10665/246107/1/9789241580496-eng.pdf [cited 2017 Nov 30]. 3. Swine influenza. Geneva: World Health Organization; 2009. Available from: http://www.who.int/mediacentre/news/statements/2009/ h1n1_20090425/en/ [cited 2017 Nov 30]. 4. WHO statement on the meeting of the International Health Regulations Emergency Committee concerning the international spread of wild poliovirus. Geneva: World Health Organization; 2014. Available from: http:// www.who.int/mediacentre/news/statements/2014/polio-20140505/en/ [cited 2016 Apr 29]. 5. Statement on the 1st meeting of the IHR Emergency Committee on the 2014 Ebola outbreak in West Africa. Geneva: World Health Organization; 2014. Available from: http://www.who.int/mediacentre/news/ statements/2014/ebola-20140808/en/ [cited 2016 Apr 29]. 6. WHO statement on the first meeting of the International Health Regulations (2005) (IHR 2005). Emergency Committee on Zika virus and observed increase in neurological disorders and neonatal malformations. Geneva: World Health Organization; 2016. Available from: http://www.who.int/ mediacentre/news/statements/2016/1st-emergency-committee-zika/en/ [cited 2016 Apr 29]. 7. International Health Regulations. (2005). IHR core capacity monitoring framework: questionnaire for monitoring progress in the implementation of IHR core capacities in States Parties. 2017 Questionnaire. Geneva: World Health Organization 2017. Available from http://apps.who.int/iris/ bitstream/10665/255756/1/WHO-WHE-CPI-2017.41-eng.pdf [cited 2017 Dec 01]. 8. Checklist and indicators for monitoring progress in the development of IHR core capacities in States Parties. Geneva: World Health Organization; 2013. Available from: http://www.who.int/iris/bitstream/10665/84933/1/ WHO_HSE_GCR_2013.2_eng.pdf [cited 2015 Sep 6]. 9. Implementation of the International Health Regulations (2005): Report of the Review Committee on the Role of the International Health Regulations (2005) in the Ebola Outbreak and Response. Geneva: World Health Organization; 2016. Available from: http://apps.who.int/gb/ebwha/ pdf_files/WHA69/A69_21-en.pdf [cited 2016 Nov 7]. 10. Implementation of the International Health Regulations (2005). Geneva: World Health Organization; 2015. Available from: http://apps.who.int/gb/ ebwha/pdf_files/WHA68/A68_22-en.pdf [cited 2016 Apr 29]. 11. Implementation of the International Health Regulations (2005): report of the review committee on second extensions for establishing national public health capacities and on IHR Implementation. Geneva: World Health Organization; 2015. Available from: http://apps.who.int/gb/ebwha/ pdf_files/WHA68/A68_22Add1-en.pdf [cited 2015 Sep 6]. 12. Tong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol. 2012 11 27;12(1):181. doi: http://dx.doi.org/10.1186/1471-2288- 12-181 PMID: 23185978 13. Suthar A, Nagata J. Strengthening global health security: a systematic review of lessons learnt from national implementation of the International Health Regulations. York: Prospero; 2015. Available from: http://www.crd. york.ac.uk/PROSPEROFILES/38719_PROTOCOL_20160404.pdf [cited 2016 Aug 26]. 14. The WHO bulletin on IHR implementation. Geneva: World Health Organization; 2016. Available from: http://www.who.int/ihr/ihrnews/en/ [cited 2016 Apr 29]. 15. Past conferences. Braintree: International Society for Disease Surveillance; 2016. Available from: http://www.healthsurveillance.org/page/ pastconferences [cited 2016 Sep 17]. 16 . Critical Appraisal Skills Programme (CASP) Qualitative Research Checklist. Oxford: Better Value Healthcare; 2016. Available from: http://www.casp-uk. net/ [cited 2016 August 5]. 17. Atkins S, Lewin S, Smith H, Engel M, Fretheim A, Volmink J. Conducting a meta-ethnography of qualitative literature: lessons learnt. BMC Med Res Methodol. 2008 04 16;8(1):21. doi: http://dx.doi.org/10.1186/1471-2288-8- 21 PMID: 18416812 18. Noyes J, Popay J. Directly observed therapy and tuberculosis: how can a systematic review of qualitative research contribute to improving services? A qualitative meta-synthesis. J Adv Nurs. 2007 Feb;57(3):227–43. doi: http:// dx.doi.org/10.1111/j.1365-2648.2006.04092.x PMID: 17233644 19. Noyes J, Hannes K, Booth A, Harris J, Harden A, Popay J, et al. Chapter 20: qualitative research and Cochrane reviews. In: Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions version 5.3.0 (updated October 2015). London: The Cochrane Collaboration, 2015. Available from http://qim.cochrane.org/supplemental-handbook-guidance [cited 2017 Dec 01]. 20. Britten N, Campbell R, Pope C, Donovan J, Morgan M, Pill R. Using meta ethnography to synthesise qualitative research: a worked example. J Health Serv Res Policy. 2002 Oct;7(4):209–15. doi: http://dx.doi. org/10.1258/135581902320432732 PMID: 12425780 21. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008 07 10;8(1):45. doi: http://dx.doi.org/10.1186/1471-2288-8-45 PMID: 18616818 22. Sandelowski M, Barroso J. Handbook for synthesizing qualitative research. New York: Springer; 2007. 23. Dixon-Woods M, Agarwal S, Jones D, Young B, Sutton A. Synthesising qualitative and quantitative evidence: a review of possible methods. J Health Serv Res Policy. 2005 Jan;10(1):45–53. doi: http://dx.doi. org/10.1177/135581960501000110 PMID: 15667704 24. Barnett-Page E, Thomas J. Methods for the synthesis of qualitative research: a critical review. BMC Med Res Methodol. 2009 08 11;9(1):59. doi: http:// dx.doi.org/10.1186/1471-2288-9-59 PMID: 19671152 25. Noblit G, Hare R. Meta-ethnography: synthesizing qualitative studies. California: Sage; 1988. doi: http://dx.doi.org/10.4135/9781412985000 26. Aguilera X, Olea A, Muñoz X. Implementación del regulamento sanitario internacional (2005): reporte de progreso. [International health regulations (2005) implementation: progress report.] Vigía (Santiago). 2012;13(27):12–8. Spanish. 27. Bakari E, Frumence G. Challenges to the implementation of International Health Regulations (2005) on preventing infectious diseases: experience from Julius Nyerere International Airport, Tanzania. Glob Health Action. 2013;6(1):20942. doi: http://dx.doi.org/10.3402/gha.v6i0.20942 28. Kool JL, Paterson B, Pavlin BI, Durrheim D, Musto J, Kolbe A. Pacific-wide simplified syndromic surveillance for early warning of outbreaks. Glob Public Health. 2012;7(7):670–81. doi: http://dx.doi.org/10.1080/17441692.2 012.699536 PMID: 22823595 29. Borchert JN, Tappero JW, Downing R, Shoemaker T, Behumbiize P, Aceng J, et al.; Centers for Disease Control and Prevention (CDC). Rapidly building global health security capacity – Uganda demonstration project, 2013. MMWR Morb Mortal Wkly Rep. 2014 Jan 31;63(4):73–6. PMID: 24476978 30. Calain P. From the field side of the binoculars: a different view on global public health surveillance. Health Policy Plan. 2007 Jan;22(1):13–20. doi: http://dx.doi.org/10.1093/heapol/czl035 PMID: 17237490 31. Chrétien JP, Yingst SL, Thompson D. Building public health capacity in Afghanistan to implement the International Health Regulations: a role for security forces. Biosecur Bioterror. 2010 Sep;8(3):277–85. doi: http://dx.doi. org/10.1089/bsp.2009.0058 PMID: 20825338 32. Craig A, Kool J, Nilles E. The Pacific experience: supporting small island countries and territories to meet their 2012 International Health Regulations (2005) commitments. West Pac Surveill Response. 2013 07 3;4(3):14–8. doi: http://dx.doi.org/10.5365/wpsar.2012.3.4.007 PMID: 24319608 33. Dagina R, Murhekar M, Rosewell A, Pavlin BI. Event-based surveillance in Papua New Guinea: strengthening an International Health Regulations (2005) core capacity. West Pac Surveill Response. 2013 07 30;4(3):19–25. doi: http://dx.doi.org/10.5365/wpsar.2013.4.2.001 PMID: 24319609 34. Friede A. Public–private partnerships in infectious disease surveillance. In: M’ikanatha NM, Lynfield R, Van Beneden CA, de Valk H, editors. Infectious disease surveillance. 2nd ed. Oxford: Wiley; 2013. pp. 647–56. doi: http:// dx.doi.org/10.1002/9781118543504.ch53 35. Gala Á, Toledo ME, Arias Y, Díaz González M, Álvarez Valdez ÁM, Estévez G, et al. Implementación del Reglamento Sanitario Internacional en Cuba: evaluación de capacidades básicas del sector salud en provincias seleccionadas [Implementation of the International Health Regulations in Cuba: evaluation of basic capacities of the health sector in selected provinces]. Pan Am J Public Health. 2012;32(3):207–16. [Spanish.]doi: http:// dx.doi.org/10.1590/S1020-49892012000900006 36. Gheorghita S, Caterinciuc N. Timely detection of outbreaks in the public health surveillance system of the Republic of Moldova. In: Vaseashta A, Khudaverdyan S, editors. Advanced sensors for safety and security. NATO Science for Peace and Security Series B: Physics and Biophysics. Dordrecht: Springer; 2013. doi: http://dx.doi.org/10.1007/978-94-007-7003-4_6 Bull World Health Organ 2018;96:110–121E| doi: http://dx.doi.org/10.2471/BLT.16.189100120 Systematic reviews International Health Regulations implementation Amitabh B Suthar et al. 37. Ortiz Gómez Y, Trujillo E, Guzmán JM. Cooperación técnica en salud entre Colombia y sus países fronterizos. Rev Panam Salud Publica. 2011 Aug;30(2):153–9. [Spanish.] PMID: 22159725 38. Hadjichristodoulou C, Mouchtouri VA, Guglielmetti P, Lemos CM, Nichols G, Paux T, et al.; SHIPSAN TRAINET partnership. Actions for prevention and control of health threats related to maritime transport in European Union. Travel Med Infect Dis. 2013 Jul-Aug;11(4):238–42. doi: http://dx.doi. org/10.1016/j.tmaid.2013.02.001 PMID: 23518234 39. Hamblion EL, Salter M, Jones J; UK Overseas Territories and Crown Dependencies IHR Project Group. Achieving compliance with the International Health Regulations by overseas territories of the United Kingdom of Great Britain and Northern Ireland. Bull World Health Organ. 2014 Nov 1;92(11):836–43. doi: http://dx.doi.org/10.2471/BLT.14.137828 PMID: 25378745 40. Harutyunyan V. International health regulations in the occupied Palestinian territory. Lancet. 2012 Oct 20;380(9851):1385–6. doi: http://dx.doi. org/10.1016/S0140-6736(12)61801-7 PMID: 23084453 41. Ihekweazu C, Ncube F, Schoub B, Blumberg L, Ruggles R, Salter M, et al. A North/South collaboration between two national public health institutes – a model for global health protection. J Public Health Policy. 2015 May;36(2):181–93. doi: http://dx.doi.org/10.1057/jphp.2014.52 PMID: 25568964 42. Johns MC, Blazes DL. International Health Regulations (2005) and the U.S. Department of Defense: building core capacities on a foundation of partnership and trust. BMC Public Health. 2010 12 3;10 Suppl 1:S4. doi: http://dx.doi.org/10.1186/1471-2458-10-S1-S4 PMID: 21143826 43. Kamradt-Scott A, Lee K, Xu J. Chapter 1: The International Health Regulations (2005). In: Lee K, Pang T, Tan Y, editors. Asia’s contribution to a global health governance framework. Abingdon: Routledge; 2013. pp. 83–98. 44. Kandun IN, Samaan G, Santoso H, Kushadiwijaya H, Juwita R, Mohadir A, et al. Strengthening Indonesia’s Field Epidemiology Training Programme to address International Health Regulations requirements. Bull World Health Organ. 2010 Mar;88(3):211–5. doi: http://dx.doi.org/10.2471/BLT.09.065367 PMID: 20428389 45. Kant L, Krishnan SK. Information and communication technology in disease surveillance, India: a case study. BMC Public Health. 2010 12 3;10 Suppl 1:S11. doi: http://dx.doi.org/10.1186/1471-2458-10-S1-S11 PMID: 21143821 46. Kasolo F, Yoti Z, Bakyaita N, Gaturuku P, Katz R, Fischer JE, et al. IDSR as a platform for implementing IHR in African countries. Biosecur Bioterror. 2013 Sep;11(3):163–9. doi: http://dx.doi.org/10.1089/bsp.2013.0032 PMID: 24041192 47. Katz R, Kornblet S. Comparative analysis of national legislation in support of the revised international health regulations: potential models for implementation in the United States. Am J Public Health. 2010 Dec;100(12):2347–53. doi: http://dx.doi.org/10.2105/AJPH.2009.180414 PMID: 20966376 48. Kicman-Gawłowska A. Nadzór nad chorobami zakaźnymi w świetle Miedzynarodowych Przepisów Zdrowotnych (2005). Przegl Epidemiol. 2008;62(4):739–49. [Polish.] PMID: 19209736 49. Kicman-Gawłowska A. Krajowy Punkt Centralny ds. Miedzynarodowych Przepisów Zdrowotnych. Przegl Epidemiol. 2009;63(1):143–7. [Polish.] PMID: 19522243 50. Leventhal A, Ramlawi A, Belbiesi A, Sheikh S, Haddadin A, Husseini S, et al. Enhanced surveillance for detection and management of infectious diseases: regional collaboration in the Middle East. Emerg Health Threats J. 2013;6(0):6. doi: http://dx.doi.org/10.3402/ehtj.v6i0.19955 PMID: 23362413 51. Lima YOR, Costa EA. Implementing International Health Regulation (2005) in the Brazilian legal-administrative system. Cien Saude Colet. 2015 Jun;20(6):1773–83. doi: http://dx.doi.org/10.1590/1413- 81232015206.06552014 PMID: 26060955 52. Liu B, Sun Y, Dong Q, Zhang Z, Zhang L. Strengthening core public health capacity based on the implementation of the International Health Regulations (IHR) (2005): Chinese lessons. Int J Health Policy Manag. 2015 04 17;4(6):381–6. doi: http://dx.doi.org/10.15171/ijhpm.2015.84 PMID: 26029897 53. Lyons S, Zidouh A, Ali Bejaoui M, Ben Abdallah M, Amine S, Garbouj M, et al. Implications of the International Health Regulations (2005) for communicable disease surveillance systems: Tunisia’s experience. Public Health. 2007 Sep;121(9):690–5. doi: http://dx.doi.org/10.1016/j. puhe.2007.02.013 PMID: 17544043 54. Masanza MM, Nqobile N, Mukanga D, Gitta SN. Laboratory capacity building for the International Health Regulations (IHR [2005]) in resource-poor countries: the experience of the African Field Epidemiology Network (AFENET). BMC Public Health. 2010 12 3;10 Suppl 1:S8. doi: http://dx.doi. org/10.1186/1471-2458-10-S1-S8 PMID: 21143830 55. May L, Chretien JP, Pavlin JA. Beyond traditional surveillance: applying syndromic surveillance to developing settings – opportunities and challenges. BMC Public Health. 2009 07 16;9(1):242. doi: http://dx.doi. org/10.1186/1471-2458-9-242 PMID: 19607669 56. Mmbuji P, Mukanga D, Mghamba J, Ahly M, Mosha F, Azima S, et al. The Tanzania Field Epidemiology and Laboratory Training Program: building and transforming the public health workforce. Pan Afr Med J. 2011;10 Supp 1:9. PMID: 22359697 57. Narain JP, Lal S, Garg R. Implementing the revised International Health Regulations in India. Natl Med J India. 2007 Sep-Oct;20(5):221–4. PMID: 18254515 58. Patel MS, Phillips CB. Strengthening field-based training in low and middle- income countries to build public health capacity: lessons from Australia’s Master of Applied Epidemiology program. Aust New Zealand Health Policy. 2009 04 9;6(1):5. doi: http://dx.doi.org/10.1186/1743-8462-6-5 PMID: 19358710 59. Paterson BJ, Kool JL, Durrheim DN, Pavlin B. Sustaining surveillance: evaluating syndromic surveillance in the Pacific. Glob Public Health. 2012;7(7):682–94. doi: http://dx.doi.org/10.1080/17441692.2012.699713 PMID: 22817479 60. Perry HN, McDonnell SM, Alemu W, Nsubuga P, Chungong S, Otten MW Jr, et al. Planning an integrated disease surveillance and response system: a matrix of skills and activities. BMC Med. 2007 08 15;5(1):24. doi: http:// dx.doi.org/10.1186/1741-7015-5-24 PMID: 17697387 61. Priotto G, Rguig A, Ziani M, Berger A, Nabeth P. Needs assessment for performance improvement of personnel in charge of epidemiological surveillance in Morocco. PLoS One. 2014 07 7;9(7):e101594. doi: http:// dx.doi.org/10.1371/journal.pone.0101594 PMID: 25000499 62. Quandelacy TM, Johns MC, Andraghetti R, Hora R, Meynard JB, Montgomery JM, et al. The role of disease surveillance in achieving IHR compliance by 2012. Biosecur Bioterror. 2011 Dec;9(4):408–12. doi: http://dx.doi. org/10.1089/bsp.2011.0053 PMID: 22074350 63. Rajatonirina S, Heraud JM, Randrianasolo L, Orelle A, Razanajatovo NH, Raoelina YN, et al. Short message service sentinel surveillance of influenza- like illness in Madagascar, 2008–2012. Bull World Health Organ. 2012 May 1;90(5):385–9. doi: http://dx.doi.org/10.2471/BLT.11.097816 PMID: 22589573 64. Rosewell A, Bieb S, Clark G, Miller G, MacIntyre R, Zwi A. Human resources for health: lessons from the cholera outbreak in Papua New Guinea. West Pac Surveill Response. 2013 07 3;4(3):9–13. doi: http://dx.doi.org/10.5365/ wpsar.2013.4.2.006 PMID: 24319607 65. Sylvester J, Kazoora H, Park M, Gitta S, Haile BH, McNabb SJ. African One Health e-surveillance initiative. Paper presented at the International Society for Disease Surveillance Conference; 2015 9–10 December; Denver, United States of America. Braintree: International Society for Disease Surveillance; 2015. 66. Standley CJ, Sorrell EM, Kornblet S, Fischer JE, Katz R. Implementation of the International Health Regulations (2005) through cooperative bioengagement. Front Public Health. 2015 10 13;3:231. doi: http://dx.doi. org/10.3389/fpubh.2015.00231 PMID: 26528463 67. Stewart-Evans J, Hall L, Czerczak S, Manley K, Dobney A, Hoffer S, et al. Assessing and improving cross-border chemical incident preparedness and response across Europe. Environ Int. 2014 Nov;72:30–6. doi: http://dx.doi. org/10.1016/j.envint.2014.03.012 PMID: 24768281 68. Stikova E, Gjorgjev D, Karadzovski Z. Strengthening the early-warning function of the surveillance system: the Macedonian experience. In: O’Connell K, Skowronski E, Sulakvelidze A, Bakanidze L, editors. Emerging and endemic pathogens. NATO Science for Peace and Security Series A: Chemistry and Biology. Dordrecht: Springer; 2010. pp. 45–58. doi: http:// dx.doi.org/10.1007/978-90-481-9637-1_6 69. International Health Regulations (2005): a brief introduction to implementation in national legislation. Geneva: World Health Organization; 2009. Available from: http://www.who.int/ihr/Intro_legislative_ implementation.pdf [cited 2017 Sep 26]. 70. Takahashi-Omoe H, Omoe K. Regulatory and scientific frameworks for zoonosis control in Japan – contributing to International Health Regulations (2005). Rev Sci Tech. 2009 Dec;28(3):957–73. doi: http://dx.doi. org/10.20506/rst.28.3.1937 PMID: 20462153 71. Teixeira MG, Costa MC, Souza LP, et al. Evaluation of Brazil’s public health surveillance system within the context of the International Health Regulations (2005). Pan Am J Public Health. 2012;32(1):49–55. PMID: 22095346 72. van Vliet JA, Haringhuizen GB, Timen A, Bijkerk P. Veranderingen in de meldingsplicht voor infectieziekten door de Wet Publieke Gezondheid. Ned Tijdschr Geneeskd. 2009;153:B79. [Dutch.] PMID: 19818190 Bull World Health Organ 2018;96:110–121E| doi: http://dx.doi.org/10.2471/BLT.16.189100 121 Systematic reviews International Health Regulations implementationAmitabh B Suthar et al. 73. Wamala JF, Okot C, Makumbi I, Natseri N, Kisakye A, Nanyunja M, et al. Assessment of core capacities for the International Health Regulations (IHR[2005]) – Uganda, 2009. BMC Public Health. 2010 Dec 3;10 Suppl 1:S9. doi: http://dx.doi.org/10.1186/1471-2458-10-S1-S9 PMID: 21143831 74. Wang Y, Li X, Yuan Y, Patel MS. A multi-method approach to curriculum development for in-service training in China’s newly established health emergency response offices. PLoS One. 2014 Jun 27;9(6):e100892. doi: http://dx.doi.org/10.1371/journal.pone.0100892 PMID: 24971602 75. Ziemann A, Rosenkötter N, Riesgo LG, Fischer M, Krämer A, Lippert FK, et al. Meeting the International Health Regulations (2005) surveillance core capacity requirements at the subnational level in Europe: the added value of syndromic surveillance. BMC Public Health. 2015 Feb 7;15(1):107. doi: http://dx.doi.org/10.1186/s12889-015-1421-2 PMID: 25879869 76. Bekshin Z, Esmagambetova A, Kazakov S, Burdakov A, Kobzhasarov D, Ukharov A. Modernization of epi-surveillance in Kazakhstan: transition to risk assessment and real-time monitoring based on situational center. In: International Society for Disease Surveillance Conference; 2015 9–10 December; Denver, United States of America. Braintree: International Society for Disease Surveillance; 2015. 77. Singh V, Mohan J, Rao UP, Dandona L, Heymann D. An evaluation of the key indicator based surveillance system for International Health Regulations (IHR) 2005. Core capacity requirements in India. In: International Society for Disease Surveillance Conference; 2013 12–13 December 2013; New Orleans, United States of America. Braintree: International Society for Disease Surveillance; 2013. 78. Country planning cycle database. Geneva: World Health Organization; 2016. Available from: http://www.nationalplanningcycles.org/ [cited 2016 Sep 17]. 79. International Health Regulations (2005): toolkit for implementation in national legislation. Geneva: World Health Organization; 2009. Available from: http://www.who.int/ihr/Toolkit_Legislative_Implementation.pdf [cited 2017 Sep 26]. 80. IHR core capacities implementation status: surveillance. Geneva: World Health Organization; 2016. Available from: http://www.who.int/gho/ihr/ monitoring/surveillance/en/ [cited 2016 Sep 17]. 81. Kluberg SA, Mekaru SR, McIver DJ, Madoff LC, Crawley AW, Smolinski MS, et al. Global capacity for emerging infectious disease detection, 1996–2014. Emerg Infect Dis. 2016 10;22(10):E1–6. doi: http://dx.doi.org/10.3201/ eid2210.151956 PMID: 27649306 82. Fleck F. How SARS changed the world in less than six months. Bull World Health Organ. 2003;81(8):625–6. PMID: 14576896 83. Heymann DL, Mackenzie JS, Peiris M. SARS legacy: outbreak reporting is expected and respected. Lancet. 2013 Mar 9;381(9869):779–81. doi: http:// dx.doi.org/10.1016/S0140-6736(13)60185-3 PMID: 23668493 84. Global strategy on human resources for health: workforce 2030. Geneva: World Health Organization; 2016. Available from: http://apps.who.int/gb/ ebwha/pdf_files/WHA69/A69_R19-en.pdf [cited 2016 Sep 17]. 85. Workload indicators of staffing need (WISN).Geneva: World Health Organization; 2016. Available from: http://www.who.int/hrh/resources/ wisn_user_manual/en/ [cited 2016 Sep 17]. 86. WHO collaborating centres for influenza and essential regulatory laboratories. Geneva: World Health Organization; 2016. http://www.who. int/influenza/gisrs_laboratory/collaborating_centres/list/en/ [cited 2016 Sep 18]. 87. Polio laboratory network. Geneva: World Health Organization; 2016. http:// apps.who.int/immunization_monitoring/laboratory_polio/en/index.html [cited 2016 Sep 17]. 88. Immunization, vaccines, and biologicals laboratory network. Geneva: World Health Organization; 2016. Available from: http://www.who.int/ immunization/monitoring_surveillance/burden/laboratory/en/ [cited 2016 Sep 18]. 89. Wang S, Lifson MA, Inci F, Liang LG, Sheng YF, Demirci U. Advances in addressing technical challenges of point-of-care diagnostics in resource- limited settings. Expert Rev Mol Diagn. 2016;16(4):449–59. doi: http:// dx.doi.org/10.1586/14737159.2016.1142877 PMID: 26777725 90. Global Polio Eradication Initiative. Financial resource requirements: 2013–2019. Geneva: World Health Organization; 2016. Available from: http://polioeradication.org/wp-content/uploads/2016/10/FRR2013- 2019_April2016_EN_A4.pdf [cited 2016 Sep 17]. 91. Political declaration on HIV and AIDS: on the fast-track to accelerate the fight against HIV and to end the AIDS epidemic by 2030. In: Seventieth United National General Assembly. 7 June 2016, Agenda item 11. Resolution A/RES/70/266. New York: United Nations; 2016. Available from: http://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/70/266 [cited 2016 Sep 17]. 92. The paradigm shift: 2016–2020. Global plan to end TB. Geneva: Stop TB Partnership; 2016. Available from: http://www.stoptb. org/assets/documents/global/plan/GlobalPlanToEndTB_ TheParadigmShift_2016-2020_StopTBPartnership.pdf [cited 2016 Sep 17]. 93. The global malaria action plan for a malaria-free world. Geneva: Roll Back Malaria Partnership; 2008. Available from: http://archiverbm.rollbackmalaria. org/gmap/gmap.pdf [cited 2016 Sep 17]. 94. IHR costing tool [Internet]. Washington: Georgetown University Center for Global Health Science and Security; 2017. Available from: http://ghscosting. org/# [cited 2017 Sep 26]. 95. Katz R, Haté V, Kornblet S, Fischer JE. Costing framework for International Health Regulations (2005). Emerg Infect Dis. 2012 Jul;18(7):1121–7. doi: http://dx.doi.org/10.3201/eid1807.120191 PMID: 22710255 96. Advancing the Global health security agenda: progress and early impact from US investment. Global Health Security Agenda Annual Report. Seoul: Global Health Security Agenda; 2017. Available from: https://www. ghsagenda.org/docs/default-source/default-document-library/ghsa- legacy-report.pdf [cited 2017 Sep 26]. 97. World Bank contributes to improved disease surveillance and health systems in West Africa following Ebola epidemic [internet]. Washington: World Bank; 2016. Available from: http://www.worldbank.org/en/news/ press-release/2016/06/29/world-bank-contributes-to-improved-disease- surveillance-and-health-systems-in-west-africa-following-ebola-epidemic [cited 2017 Sep 26]. 98. Protecting humanity from future health crises. Report of the High-level Panel on the Global Response to Health Crises. New York: United Nations; 2016. Available from: http://www.un.org/News/dh/infocus/HLP/2016-02- 05_Final_Report_Global_Response_to_Health_Crises.pdf [cited 2016 Sep 17]. 99. Ebola Interim Assessment Panel. Report by the Secretariat.In: Sixty-eighth World Health Assembly. Geneva, 18–26 May 2015. Provisional agenda item 16.1. A68/25. Geneva: World Health Organization; 2015. Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_25-en.pdf [cited 2016 Sep 17]. 100. Commission on a Global Health Risk Framework for the Future. The neglected dimension of global security: a framework to counter infectious disease crises. Washington: National Academy of Medicine; 2016. Available from: https://nam.edu/wp-content/uploads/2016/01/Key-Messages-The- Neglected-Dimension-of-Global-Security1.pdf [cited 2017 Dec 01]. 101. Moon S, Sridhar D, Pate MA, Jha AK, Clinton C, Delaunay S, et al.; Harvard- LSHTM Independent Panel on the Global Response to Ebola. Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola. Lancet. 2015 Nov 28;386(10009):2204–21. doi: http://dx.doi. org/10.1016/S0140-6736(15)00946-0 PMID: 26615326 102. Keogh-Brown MR, Smith RD. The economic impact of SARS: how does the reality match the predictions? Health Policy. 2008 Oct;88(1):110–20. doi: http://dx.doi.org/10.1016/j.healthpol.2008.03.003 PMID: 18436332 103. The economic impact of Ebola on sub-Saharan Africa: updated estimates for 2015. Washington: World Bank; 2015. Available from: http://documents. worldbank.org/curated/en/541991468001792719/pdf/937210REVISED000J an02002015000FINAL.pdf [cited 2016 Sep 29]. 104. WTO agreements and public health: a joint study by the WHO and WTO Secretariet. Geneva: World Trade Organization; 2002. Available from: https:// www.wto.org/english/res_e/booksp_e/who_wto_e.pdf [cited 2016 Sep 29]. 105. State Party monitoring questionnaire for core capacities relating to the International Health Regulations (2005). Geneva: World Health Organization; 2016. Available from: http://apps.who.int/iris/bitstream/10665/246237/1/ WHO-HSE-GCR-2016.16-eng.pdf ([cited 2016 Sep 19]. 106. Rakotoarisoa A, Randrianasolo L, Tempia S, Guillebaud J, Razanajatovo N, Randriamampionona L, et al. Evaluation of the influenza sentinel surveillance system in Madagascar, 2009–2014. Bull World Health Organ. 2017 May 1;95(5):375–81. doi: http://dx.doi.org/10.2471/BLT.16.171280 PMID: 28479639 107. IHR (2005) monitoring and evaluation framework: Joint External Evaluation tool (JEE tool). Geneva: World Health Organization; 2016. Available from: http://www.who.int/ihr/publications/WHO_HSE_GCR_2016_2/en/ [cited 2017 Oct 22]. 108. Joint external evaluation mission reports. Geneva: World Health Organization; 2017. Available from: http://www.who.int/ihr/procedures/ mission-reports/en/ [cited 2017 Oct 22]. Bull World Health Organ 2018;96:110–121E| doi: http://dx.doi.org/10.2471/BLT.16.189100 121A Systematic reviews International Health Regulations implementationAmitabh B Suthar et al. Ta bl e 1. Su m m ar y o f a rt icl es in clu de d in th e sy st em at ic re vi ew o f t he im pl em en ta tio n of th e In te rn at io na l H ea lth R eg ul at io ns (2 00 5) Au th or , y ea r Da ta co lle ct io n ye ar (s ) Pu bl ica tio n ye ar Se tt in g W HO R eg io n St ud y d es ig n Qu al ity a ss es s- m en t s co re (o ut of 1 0) a IH R co re ca pa cit ie s re po rt ed b Ca la in , 2 00 73 0 N ot re po rt ed 20 07 Ca m bo di a, L ao P eo pl e’s D em oc ra tic R ep ub lic , I nd ia a nd U ga nd a Af ric a, S ou th -E as t As ia a nd W es te rn Pa ci fic Ca se st ud y of th e al te rn at iv e vi ew o f d on or -d riv en su rv ei lla nc e bu ild in g N /A 1, 2 , 3 , 4 , 7 , 8 Ly on s e t a l., 20 07 53 20 07 20 07 Tu ni sia Ea st er n M ed ite rra ne an Ev al ua tio n of su rv ei lla nc e sy st em s t o id en tif y im pl ic at io ns o f I H R (2 00 5) im pl em en ta tio n 8 1, 3 , 4 , 6 , 7 , 8 N ar ai n et a l., 20 07 57 20 07 20 07 In di a So ut h- Ea st A sia Ev al ua tio n of th e st at us o f i m pl em en ta tio n of IH R co re c ap ac iti es N /A 1, 2 , 3 , 6 , 7 , 8 Pe rr y et a l., 20 07 60 N ot re po rt ed 20 07 Af ric a, C en tra l A m er ic a an d Ph ili pp in es Af ric a, A m er ic as a nd W es te rn P ac ifi c Q ua lit at iv e st ud y of su rv ei lla nc e ob je ct iv es , su rv ei lla nc e ca se d efi ni tio ns , a ct io n th re sh ol ds an d re co m m en da tio ns fo r 1 9 pr io rit y in fe ct io us di se as es 8 1, 3 , 4 Ki cm an -G aw lo w sk a, 20 08 48 N ot re po rt ed 20 08 Po la nd Eu ro pe Ev al ua tio n of c oo rd in at io n, su rv ei lla nc e an d co m m un ic at io n in tr an sit io ni ng to IH R (2 00 5) re qu ire m en ts N /A 1, 2 , 3 , 4 , 6 Ki cm an -G aw lo w sk a, 20 09 49 20 07 –2 00 9 20 09 Po la nd Eu ro pe Ev al ua tio n of th e na tio na l f oc al p oi nt a nd st at us o f im pl em en ta tio n of IH R (2 00 5) N /A 2, 5 , 7 M ay e t a l., 20 09 55 20 09 20 09 Au st ra lia , B an gl ad es h, B ur ki na Fa so , C os ta R ic a, C hi na , T ai w an , Cô te d ’Iv oi re , E gy pt , E rit re a, Fr en ch G ui an a, In do ne sia , Ja m ai ca , L ao P eo pl e’s D em oc ra tic R ep ub lic , P er u, So lo m on Is la nd s, U ni te d Re pu bl ic o f T an za ni a, U ga nd a, U SA a nd V an ua tu Af ric a, A m er ic as , Ea st er n M ed ite rra ne an , So ut h- ea st A sia a nd W es te rn P ac ifi c Q ua lit at iv e st ud y of th e ap pl ic at io n of sy nd ro m ic su rv ei lla nc e to IH R (2 00 5) N /A 3, 6 Pa te l & P hi lli ps , 2 00 95 8 20 07 –2 00 9 20 09 Au st ra lia W es te rn P ac ifi c Ev al ua tio n of d iff er en t e du ca tio na l a nd tr ai ni ng m od el s a nd le ss on s l ea rn t N /A 3, 7 St ik ov a et a l., 20 10 68 N ot re po rt ed 20 10 Th e fo rm er Y ug os la v Re pu bl ic o f M ac ed on ia Eu ro pe Ca se st ud y of sy nd ro m ic su rv ei lla nc e N /A 1, 2 , 3 , 6 , 7 , 8 Ta ka ha sh i-O m oe & O m oe , 20 09 70 N ot re po rt ed 20 09 Ja pa n W es te rn P ac ifi c Ev al ua tio n of th e re gu la to ry fr am ew or k fo r pr ev en tin g zo on os es in Ja pa n N /A 1, 2 Va n Vl ie t e t a l., 20 09 72 20 09 20 09 N et he rla nd s Eu ro pe Ca se st ud y de sc rib in g a ne w p ub lic h ea lth a ct re ga rd in g no tifi ca tio n of c om m un ic ab le d ise as es an d w ha t w ill c ha ng e fo r p ro vi de rs N /A 1, 7 Ch re tie n et a l., 20 10 31 20 09 20 10 Af gh an ist an Ea st er n M ed ite rra ne an Ev al ua tio n of c ha lle ng es to im pl em en tin g IH R (2 00 5) b y co un tri es w ith a ct iv e co nfl ic ts , a nd pr op os ed ro le o f c oo rd in at ed in te rn at io na l m ili ta ry in su pp or tin g IH R (2 00 5) N /A 1, 2 , 3 , 4 , 7 , 8 (c on tin ue s. . . ) Amitabh B Suthar et al.International Health Regulations implementation Systematic reviews 121B Bull World Health Organ 2018;96:110–121E| doi: http://dx.doi.org/10.2471/BLT.16.189100 Au th or , y ea r Da ta co lle ct io n ye ar (s ) Pu bl ica tio n ye ar Se tt in g W HO R eg io n St ud y d es ig n Qu al ity a ss es s- m en t s co re (o ut of 1 0) a IH R co re ca pa cit ie s re po rt ed b Jo hn s & B la ze s, 20 10 42 20 08 –2 00 9 20 10 Al l l oc at io ns w ith U SA D ep ar tm en t o f D ef en ce st aff Af ric a, A m er ic as , So ut h- Ea st A sia , Eu ro pe , W es te rn Pa ci fic a nd E as te rn M ed ite rra ne an Ev al ua tio n of th e D ep ar tm en t o f D ef en ce ’s w or k in ca pa ci ty -b ui ld in g in a ll W H O re gi on s N /A 2, 3 , 4 , 6 , 7 , 8 Ka nd un e t a l., 20 10 44 20 07 –2 00 9 20 10 In do ne sia So ut h- Ea st A sia Q ua lit at iv e st ud y of th e na tio na l F ie ld Ep id em io lo gy Tr ai ni ng P ro gr am m e w or k pl an ba se d on th e ex ist in g pr og ra m m e an d pr oj ec te d hu m an re so ur ce n ee ds N /A 1, 7 Ka nt & K ris hn an , 2 01 04 5 20 10 20 10 In di a So ut h- Ea st A sia Ev al ua tio n of th e st at us a nd p ro gr es s o f I H R (2 00 5) im pl em en ta tio n N /A 3, 4 , 5 , 6 , 7 , 8 Ka tz & K or nb le t, 20 10 47 20 07 –2 01 0 20 10 Au st ra lia , C an ad a, G er m an y an d In di a Am er ic as , S ou th -E as t As ia , E ur op e an d W es te rn P ac ifi c As se ss m en t o f I H R (2 00 5) im pl em en ta tio n st ra te gi es 7 1, 2 , 3 , 5 M as an za e t a l., 20 10 54 20 07 –2 01 0 20 10 Bu rk in a Fa so , K en ya , M al i, N ig er N ig er ia , R w an da , S ou th A fri ca , To go a nd U ni te d Re pu bl ic o f Ta nz an ia Af ric a Ca se st ud y of th e Af ric an F ie ld E pi de m io lo gy N et w or k N /A 1, 3 , 4 , 7 , 8 W am al a et a l., 20 10 73 20 09 20 10 U ga nd a Af ric a Q ua lit at iv e st ud y of n at io na l I H R (2 00 5) c or e ca pa ci tie s 8 1, 2 , 3 , 4 , 5 , 6, 7 , 8 G om ez e t a l., 20 11 37 N ot re po rt ed 20 11 Co lo m bi a, P an am a, E cu ad or , Br az il an d Pe ru Am er ic as Q ua lit at iv e st ud y of re gi on al c ol la bo ra tio n fo r ac hi ev in g IH R (2 00 5) c or e ca pa ci tie s a nd th e M ill en ni um D ev el op m en t G oa ls ba se d on th e re vi ew o f d oc um en ts a nd in fo rm at io n pr ov id ed b y ke y st ak eh ol de rs in th is fie ld 8 3, 7 M m bu ji et a l., 20 11 56 20 07 –2 01 1 20 11 U ni te d Re pu bl ic o f T an za ni a Af ric a Ca se st ud y of th e Fi el d Ep id em io lo gy a nd La bo ra to ry Tr ai ni ng P ro gr am m e an d pr og re ss in in cr ea sin g ca pa ci ty fo r s ur ve ill an ce a nd la bo ra to ry co re c ap ac iti es N /A 1, 2 , 4 , 5 , 7 , 8 Q ua nd el ac y et a l., 20 11 62 20 10 20 11 D jib ou ti, F ra nc e, F re nc h Gu ia na , Pe ru , P hi lip pi ne s a nd U SA Am er ic as , E as te rn M ed ite rra ne an , Eu ro pe a nd W es te rn Pa ci fic Ca se st ud y of a c on fe re nc e to g at he r a nd sh ar e ex pe rie nc es o f s ur ve ill an ce c ap ac ity -b ui ld in g an d IH R (2 00 5) im pl em en ta tio n N /A 3, 4 , 7 , 8 Ag ui le ra e t a l., 20 12 26 N ot re po rt ed 20 12 Ch ile Am er ic as Ev al ua tio n of p ro gr es s m ad e in im pl em en tin g IH R (2 00 5) N /A 2, 3 , 4 , 5 , 6 , 7, 8 G al a et a l., 20 12 35 20 11 20 12 Cu ba Am er ic as Q ua lit at iv e st ud y of a n in st ru m en t e va lu at in g ba sic ca pa ci tie s s uc h as le gi sla tio n an d re sp on se to pu bl ic h ea lth e m er ge nc ie s 8 1, 3 , 4 , 5 , 6 , 7 H ar ut yu ny an , 2 01 24 0 20 12 20 12 W es t B an k an d G az a St rip Ea st er n M ed ite rra ne an Ev al ua tio n of p ro gr es s a nd c ha lle ng es in im pl em en ta tio n of IH R (2 00 5) N /A 1 (. . . co nt in ue d) (c on tin ue s. . . ) Amitabh B Suthar et al. International Health Regulations implementation Systematic reviews 121CBull World Health Organ 2018;96:110–121E| doi: http://dx.doi.org/10.2471/BLT.16.189100 Au th or , y ea r Da ta co lle ct io n ye ar (s ) Pu bl ica tio n ye ar Se tt in g W HO R eg io n St ud y d es ig n Qu al ity a ss es s- m en t s co re (o ut of 1 0) a IH R co re ca pa cit ie s re po rt ed b Ko ol e t a l., 20 12 28 20 10 –2 01 2 20 12 Pa ci fic Is la nd S ta te s a nd Te rri to rie sc W es te rn P ac ifi c Q ua lit at iv e st ud y de sc rib in g ex pe rie nc e w ith sy nd ro m ic su rv ei lla nc e fo r e ar ly w ar ni ng in di ca to rs 8 2, 3 , 4 , 6 , 8 Pa te rs on e t a l., 20 12 59 20 11 20 12 Fi ve P ac ifi c Isl an d St at es a nd Te rri to rie sd W es te rn P ac ifi c Ca se st ud y of th e sy nd ro m ic su rv ei lla nc e sy st em an d an al ys is of sy nd ro m ic d at a re po rt ed to W H O by a ll pa rt ic ip at in g te rri to rie s 8 1, 2 , 3 , 6 , 7 Ra ja to ni rin a et a l., 20 12 63 20 07 –2 01 1 20 12 M ad ag as ca r Af ric a Ca se st ud y of th e su rv ei lla nc e sy st em N A 2, 3 , 6 , 7 Te ix ei ra e t a l., 20 12 71 20 08 –2 00 9 20 12 Br az il Am er ic as Q ua lit at iv e st ud y to a ss es s h ea lth sy st em su rv ei lla nc e st ru ct ur e an d su rv ei lla nc e an d re sp on se p ro ce du re s r eg ar di ng c om pl ia nc e w ith IH R (2 00 5) 8 1, 2 , 3 , 4 , 6 , 7, 8 Ba ka ri & Fr um en ce , 2 01 32 7 20 13 20 13 U ni te d Re pu bl ic o f T an za ni a Af ric a Q ua lit at iv e st ud y of n at io na l I H R (2 00 5) im pl em en ta tio n us in g in -d ep th in te rv ie w s, fo cu s gr ou p di sc us sio ns a nd d oc um en t r ev ie w s 8 1, 2 , 3 , 4 , 5 , 6, 7 , 8 Cr ai g et a l., 20 13 32 20 12 20 13 Pa ci fic Is la nd S ta te s a nd Te rri to rie se W es te rn P ac ifi c Ev al ua tio n of a ta ilo re d to ol to m ee t o bl ig at io ns to IH R (2 00 5) N /A 3, 4 , 5 , 8 D ag in a et a l., 20 13 33 20 09 –2 01 2 20 13 Pa pu a N ew G ui ne a W es te rn P ac ifi c Ev al ua tio n of th e pe rfo rm an ce o f t he e ve nt -b as ed su rv ei lla nc e sy st em 8 2, 3 , 4 , 6 , 7 , 8 Fr ie de , 2 01 33 4 20 12 20 13 Ca m bo di a, C hi na , I sr ae l, J or da n, La o Pe op le ’s D em oc ra tic Re pu bl ic , M ya nm ar , T ha ila nd , U SA , V ie t N am a nd W es t b an k an d G az a St rip Am er ic as , E as te rn M ed ite rra ne an , Eu ro pe , S ou th -E as t As ia a nd W es te rn Pa ci fic Ca se st ud y an al ys in g ex am pl es fr om o th er co un tri es in fu nd in g pu bl ic h ea lth a nd IH R (2 00 5) im pl em en ta tio n co m pa re d w ith th e U SA N /A 1, 3, 4, 5, 7, 8 Gh eo rg hi ta & C at er in ci uc , 20 13 36 N ot re po rt ed 20 13 Re pu bl ic o f M ol do va Eu ro pe Ca se st ud y of a n at io na l e le ct ro ni c re po rt in g an d su rv ei lla nc e sy st em N /A 1, 2 , 3 , 4 , 5 , 6, 7 , 8 H ad jic hr ist od ou lo ua e t a l., 20 13 38 20 08 –2 01 1 20 13 Eu ro pe an U ni on Eu ro pe Ev al ua tio n of a n ee ds a ss es sm en t p ro je ct , a m an ua l o f E ur op ea n st an da rd s a nd b es t p ra ct ic es , an d tra in in g m at er ia ls an d co ur se s. D es cr ip tio n of sh ip -t o- po rt a nd p or t- to -p or t w eb -b as ed co m m un ic at io n ne tw or ks a nd d at ab as e fo r re co rd in g IH R sh ip sa ni ta tio n ce rt ifi ca te s 8 1, 2 , 3 , 7 Ka m ra dt -S co tt e t a l., 20 13 43 20 09 –2 01 0 20 13 Ch in a, Ja pa n, R ep ub lic o f K or ea an d Th ai la nd So ut h- Ea st A sia , W es te rn P ac ifi c Ev al ua tio n of c on tri bu tio n m ad e by se le ct ed co un tri es to th e IH R (2 00 5) re vi sio n pr oc es s an d ho w th es e go ve rn m en ts a re p ro gr es sin g in im pl em en tin g re vi se d IH R N /A 1, 2 , 3 , 4 , 5 Ka so lo e t a l., 20 13 46 20 12 20 13 Af ric a Af ric a As se ss m en t a nd re po rt o n In te gr at ed D ise as e Su rv ei lla nc e an d Re sp on se fo r b ui ld in g IH R (2 00 5) co re c ap ac iti es N /A 2, 3 , 4 , 6 , 7 , 8 Le ve nt ha e t a l., 20 13 50 20 07 –2 01 3 20 13 Isr ae l, J or da n an d W es t B an k an d G az a St rip Ea st er n M ed ite rra ne an a nd Eu ro pe Ca se st ud y of th e M id dl e Ea st C on so rt iu m fo r In fe ct io us D ise as e Su rv ei lla nc e N /A 1, 2 , 3 , 5 , 6 , 7, 8 (. . . co nt in ue d) (c on tin ue s. . . ) Amitabh B Suthar et al.International Health Regulations implementation Systematic reviews 121D Bull World Health Organ 2018;96:110–121E| doi: http://dx.doi.org/10.2471/BLT.16.189100 Au th or , y ea r Da ta co lle ct io n ye ar (s ) Pu bl ica tio n ye ar Se tt in g W HO R eg io n St ud y d es ig n Qu al ity a ss es s- m en t s co re (o ut of 1 0) a IH R co re ca pa cit ie s re po rt ed b Ro se w el l e t a l., 20 13 64 20 09 –2 01 2 20 13 Pa pu a N ew G ui ne a W es te rn P ac ifi c Ev al ua tio n of m an ag em en t o f h um an re so ur ce s i n fu tu re h ea lth e m er ge nc ie s N /A 1, 2 , 7 Si ng h et a l., 20 13 77 N ot re po rt ed N ot re po rt ed In di a (A nd hr a Pr ad es h) So ut h- Ea st A sia Ca se st ud y an d re vi ew o f f ac to rs a ffe ct in g ou tc om es o f a su rv ei lla nc e pr oj ec t 8 2, 3 , 8 Bo rc he rt e t a l., 20 14 29 20 13 20 14 U ga nd a Af ric a Ca se st ud y of th e ra pi d gl ob al h ea lth se cu rit y en ha nc em en ts ta rg et in g la bo ra to ry sy st em s, in fo rm at io n sy st em s a nd c oo rd in at io n of in fo rm at io n th ro ug h em er ge nc y op er at io ns ce nt re s N /A 1, 2 , 3 , 4 , 5 , 6, 7 , 8 H am bl io n et a l., 20 14 39 20 12 –2 01 4 20 14 Al l o ve rs ea s t er rit or ie s o f t he U ni te d Ki ng do m Am er ic as , S ou th -E as t As ia a nd E ur op e Ev al ua tio n of st at us o f I H R (2 00 5) c om pl ia nc e an d ap pr op ria te m ea su re s t o en su re c om pl ia nc e by Ju ne 2 01 4 6 1, 2 , 3 , 4 , 7 , 8 Pr io tto e t a l., 20 14 61 20 10 –2 01 1 20 14 M or oc co Ea st er n M ed ite rra ne an Ev al ua tio n of a st ra te gy to st re ng th en th e su rv ei lla nc e sy st em a nd w or kf or ce b y id en tif yi ng te ch ni ca l c ap ac iti es a nd tr ai ni ng n ee ds of p ub lic h ea lth o ffi ce rs 8 1, 2 , 3 , 7 St ew ar t- Ev an s e t a l., 20 14 67 N ot re po rt ed 20 13 Eu ro pe an U ni on Eu ro pe Q ua lit at iv e st ud y of e xp os ur e as se ss m en t ca pa bi lit ie s a nd c om m un ic at io n pa th w ay s be tw ee n ex po su re a ss es so rs a nd p ub lic h ea lth ri sk as se ss or s 8 3 W an g et a l., 20 14 74 20 10 20 14 Ch in a W es te rn P ac ifi c Ev al ua tio n of a m ul ti- m et ho d tra in in g ne ed s as se ss m en t, in cl ud in g re vi ew s o f c om pe te nc y do m ai ns n ee de d to im pl em en t I H R (2 00 5) a s w el l as p ol ic ie s a nd e m er ge nc y re gu la tio ns 9 1, 2 , 3 , 4 , 5 , 7 Be ks hi n et a l., 20 15 76 N ot re po rt ed 20 15 Ka za kh st an Eu ro pe Ca se st ud y of a ct io ns ta ke n to im pr ov e su rv ei lla nc e an d ris k as se ss m en t 3 2, 3 , 5 , 6 Ih ek w ea zu e t a l., 20 15 41 20 11 –2 01 5 20 15 So ut h Af ric a an d U ni te d Ki ng do m Eu ro pe , A fri ca Ca se st ud y of a w el l s up po rt ed c ol la bo ra tio n be tw ee n tw o pu bl ic h ea lth in st itu te s w ith si m ila r m an da te s ( H ea lth P ro te ct io n Ag en cy o f P ub lic H ea lth E ng la nd c ol la bo ra tio n w ith th e N at io na l In st itu te fo r C om m un ic ab le D ise as e) N /A 1, 2 , 3 , 4 , 7 , 8 Li m a & Co st a, 2 01 55 1 20 11 20 15 Br az il Am er ic as Ca se st ud y of h ow IH R (2 00 5) h as b ee n in co rp or at ed in to th e le ga l a nd a dm in ist ra tiv e sy st em 10 1, 2 , 3 , 4 , 6 , 7 Li u et a l., 20 15 52 20 14 –2 01 5 20 15 Ch in a W es te rn P ac ifi c Ev al ua tio n of IH R (2 00 5) a cc om pl ish m en ts a nd op po rt un iti es N /A 1, 2 , 4 , 5 , 6 , 7, 8 (. . . co nt in ue d) (c on tin ue s. . . ) Amitabh B Suthar et al. International Health Regulations implementation Systematic reviews 121EBull World Health Organ 2018;96:110–121E| doi: http://dx.doi.org/10.2471/BLT.16.189100 Au th or , y ea r Da ta co lle ct io n ye ar (s ) Pu bl ica tio n ye ar Se tt in g W HO R eg io n St ud y d es ig n Qu al ity a ss es s- m en t s co re (o ut of 1 0) a IH R co re ca pa cit ie s re po rt ed b St an dl ey e t a l., 20 15 66 N ot re po rt ed 20 15 Ca na da , I ra q, K en ya , U ga nd a, U ni te d Ki ng do m , a nd U SA Af ric a, A m er ic as , Ea st er n M ed ite rra ne an a nd Eu ro pe Ev al ua tio n of e xi st in g he al th se cu rit y fra m ew or ks an d th e ex te nt to w hi ch IH R (2 00 5) a nd th e Gl ob al H ea lth S ec ur ity A ge nd a ov er la p ba se d on pr io rit ie s f or d ev el op in g an d ex ec ut in g bi os ec ur ity en ga ge m en t p ro gr am m es 8 1 Sy lv es te r e t a l., 20 15 65 N ot re po rt ed 20 15 Bu rk in a Fa so , C am er oo n, K en ya , N ig er ia a nd U ga nd a Af ric a Ev al ua tio n of e -s ur ve ill an ce sy st em s 6 1, 3 Zi em an n et a l., 20 15 75 N ot re po rt ed 20 15 Au st ria , B el gi um , D en m ar k, Fr an ce , G er m an y, Ire la nd , I ta ly , Sp ai n, S w ed en a nd U ni te d Ki ng do m Eu ro pe Ev al ua tio n of th e be ne fit s a nd p itf al ls of sy nd ro m ic su rv ei lla nc e N /A 3 IH R: In te rn at io na l H ea lth R eg ul at io ns ; N /A : n ot a pp lic ab le ; W HO : W or ld H ea lth O rg an iza tio n. a Cr iti ca l A pp ra isa l S ki lls P ro gr am m e qu al ita tiv e re se ar ch c he ck lis t s um m ar y sc or e fo r e lig ib le st ud ie s ( se e Ta bl e 2 fo r f ul l q ua lit y as se ss m en t). 16 b IH R co re c ap ac iti es : 1 = n at io na l l eg isl at io n; p ol ic y an d fin an ci ng ; 2 = co or di na tio n an d na tio na l f oc al p oi nt c om m un ic at io n; 3 = su rv ei lla nc e; 4 = re sp on se ; 5 = p re pa re dn es s; 6 = ri sk c om m un ic at io n; 7 = h um an re so ur ce s; 8 = la bo ra to ry (B ox 1 ).7 c Am er ic an S am oa (U SA ), Co ok Is la nd s, Fe de ra te d St at es o f M ic ro ne sia , F iji, F re nc h Po ly ne sia , G ua m (U SA ), Ki rib at i, M ar sh al l i sla nd s, N au ru , N ew C al ed on ia (F ra nc e) , N iu e, N or th er n M ar ia na s I sla nd s ( US A) , P al au , P ap ua N ew G ui ne a, S am oa , S ol om on Isl an ds , T ok el au , T on ga , T uv al u, W al lis a nd F ut un a (F ra nc e) . d Co ok Is la nd s, Fi ji, Ki rib at i, N au ru , T uv al u, A m er ic an S am oa (U SA ), Gu am (U SA ), Pa la u, P ap ua N ew G ui ne a, S ol om on Is la nd s a nd To ng a. e Co ok Is la nd s, Fe de ra te d St at es o f M ic ro ne sia , F iji, K iri ba ti, M ar sh al l I sla nd s, N au ru , N ew C al ed on ia (F ra nc e) , N or th er n M ar ia na s I sla nd s ( US A) , N iu e, P al au , P ap ua N ew G ui ne a, P itc ai rn Is la nd s ( Un ite d Ki ng do m ), Sa m oa , S ol om on Is la nd s, To ng a, To ke la u, Tu va lu , V an ua tu a nd W al lis a nd F ut un a (F ra nc e) . (. . . co nt in ue d)