This paper presents an analysis of the subjective assessment of performance at two points in time related to MBDS countries' responses to the 2009-H1N1 pandemic. Performance early during the pandemic and post-pandemic was reported by senior health leaders in six countries in the Mekong Basin, all of whom were heavily involved in their countries' pandemic response. These countries had formally organized themselves eight years earlier for a new type of transnational cooperation - a sub-regional network for cooperation in disease surveillance, prevention and control that reached from the central government level out to provincial and local cross-border operational sites. Based on the judgments of MBDS Country Coordinators, elements of pandemic preparedness at national and sub-regional levels identified as problematic from the 2006-2007 MBDS exercises (many of the specific items included in the surveys reported here) were performed relatively early and well in the responses to 2009-H1N1 influenza, as perceived both early during the pandemic (June 2009) and post-pandemic (December 2010). Important contributors to these successes included extensive pandemic influenza planning, political leadership and government structure, the involvement of multiple government ministries in the pandemic response, and having carried out pandemic preparedness exercises including the MBDS-sponsored exercises in 2006-2007, which were the first exercises ever carried out in all MBDS countries except Thailand. Cambodia and Thailand in particular, and Myanmar to only a slightly lesser degree, felt that their public health responses were better in 2009 and 2010 than they would have been in 2006.
Most performance indicators related to responses within countries; the role of MBDS cooperation in contributing to better pandemic preparedness in these countries cannot be assessed directly from our surveys. However, while the quantitative scores indicate that MBDS cooperation was not the principal driver of pandemic response in the individual countries (a reasonable and legitimate perspective), performance in surveillance and information sharing and risk communications with other MBDS countries and with the MBDS coordinator were generally judged as good. Moreover, the qualitative responses also suggest that most MBDS countries value MBDS communications and cooperation and seek to improve them - Cambodia, China, Myanmar and Vietnam all commented explicitly in this regard. These findings lend support to a general conclusion that MBDS cooperation added value to the pandemic responses across these countries. Somewhat troubling, however, is the wide variability (across the entire 5-point range of ratings, Table 5) in the value different countries attached to MBDS cooperation, or at least to the specific elements included in the surveys--the MOU, action plan, and role of other MBDS countries.
The ultimate outcomes of interest are better system capabilities and better health in the populations of these countries. Findings from the surveys reported here suggest that the MBDS cooperation added value to their public health preparedness and pandemic response. Earlier experiences had already included several instances of cooperative cross-border outbreak detection and response. The quantitative and qualitative responses in the surveys reported here pointed to a few areas for further attention, including laboratory capacity, risk communications, electronic communications and local cross-border cooperation. Several of these are already included in the MBDS Master Plan for 2011-2016, the core strategies of which capture some of the key capabilities needed for pandemic preparedness: cross-border cooperation in surveillance and response; coordination between animal and human health; community-based surveillance; epidemiology capability; information and communications capability; laboratory capability; risk communications; and policy research . It is reasonable to expect that these capabilities, within the MBDS community and across this and other regions, will improve both public health systems and health outcomes by enabling more-timely and better detection, communications, coordinated containment, and control of the next small outbreak or the next major pandemic.
The strengths of this paper include its focus on sub-regional response (an emerging trend in global public health), the use of surveys both during and after the pandemic (to assess early progress and needs for improvement as well as overall performance after the hectic pace of pandemic response had subsided) and the fact that the country surveys, though not large in number, were completed by senior health officials who were knowledgeable and heavily involved in their country's pandemic response. The weaknesses of the paper can be broken into three categories: the reliance on subjective responses from a small number of respondents, the inability to assess how different activities impacted outcomes across countries, and the limited ability to assess how and the extent to which the MBDS sub-regional collaboration influenced their pandemic response.
The surveys reflect subjective judgments of individual health leaders in the six MBDS countries related to their respective country's pandemic response early during the pandemic and again post-pandemic. While more objective measures, more rigorous data collection methods, and the views from a larger number of country officials may have enhanced the validity of the results, we believe that these results had sufficient face validity for the practical purposes intended - to guide further improvements during the pandemic (from the 2009 survey) and provide useful insights to guide the future actions (from the 2010 survey).
An important aspect of quality improvement is the ability to iteratively test different interventions to see how effective each one is and which interventions work better than others. In this work we were not able to directly assess whether or the extent to which specific activities taken by each country resulted in different outcomes. For example, we cannot directly assess whether or not the decision of Cambodia to limit travel resulted in better outcomes (such as slower disease spread) than the other five countries that did not restrict travel. We also cannot link perceived performance quality to actual outcomes.
Our survey contained some information on how MBDS countries collaborated together during the pandemic. Our ability to assess what aspects of that collaboration resulted in optimal responses is limited. In addition, we have only a limited knowledge of how MBDS collaborative planning prior to the pandemic directly or indirectly impacted their national or collective sub-regional response. In a more ideal circumstance, a baseline survey would have been conducted prior to all MBDS planning and would not require participants to hypothetically conjecture how their responses might have differed prior to their focused pandemic planning efforts.
MBDS was founded upon a principle of coordinated actions for the common regional good and rapid and open communications across the MBDS community. Despite this, there was considerable variability in the timing of initiation of communications across MBDS countries and with the MBDS Coordinating Office during the 2009-2010 response. From their early experiences, Country Coordinators identified some priorities for MBDS action during 2009-2010, and they offered further ideas for improvement post-pandemic. By the end of the pandemic, some countries felt their performance in one or more broad areas and for specific activities had improved since 2009, but other countries rated their 2010 performance as less effective than that in 2009.
We believe it was useful to examine public health system performance in a real situation--the 2009-H1N1 pandemic. As might be expected, the MBDS leaders identified areas where early pandemic response was judged to be good to excellent and other areas where they intended to target their improvement efforts in the near term. The 2009 survey results were presented to a large MBDS conference in August 2009 in Kunming, China, and MBDS leaders incorporated some of the survey's findings into their MBDS operational plans for the next two years. Most of these plans have not yet received funding support, so assessment of actual improvements since 2009 has been limited. The information from the follow-up survey should also feed into the planning process within countries and across the MBDS cooperative community.