Introduction
Health security and preparedness are crucial for nations to effectively prevent, detect, and respond to a wide range of global health threats—including infectious disease epidemics, disasters, and bioterrorism—in today’s interconnected world [
1,
2]. In this context, the electronic State Party Self-Assessment Annual Reporting mechanism (e-SPAR) and the global health security (GHS) index provide comprehensive frameworks that enable systematic evaluation and comparison of countries’ capabilities in these critical areas [
3,
4].
The International Health Regulation (IHR) 2005 is a legal instrument developed by the World Health Organization (WHO) to enhance the ability of signatory states to manage public health risks. States Parties are required to establish minimum capacities for surveillance and response to public health events, and the effectiveness of the IHR depends on full adherence and compliance by all signatories. Implementation is reported by the States Parties and reviewed by the Director-General of the World Health Assembly. Countries use the e-SPAR tool for annual self-assessment reporting, which covers 35 indicators across 15 IHR capacities, each evaluated using 1 to 3 specific indicators and further detailed by additional attributes. Following the World Health Assembly each year, the e-SPAR questionnaire is distributed to facilitate multisectoral self-assessment and comprehensive data collection [
5].
The GHS index assesses health security capabilities in 195 nations. It enhances global preparedness for epidemics by providing objective data that holds governments accountable for pandemic readiness investments, supports evidence-based policymaking for resource allocation, and establishes benchmarks for biosecurity and pandemic preparedness. The 2021 GHS index evaluated countries across 6 categories, 37 indicators, and 171 questions using publicly available data. By contextualizing health security within broader factors such as political stability, the Joint External Evaluation, and health system robustness the index promotes transparency regarding national deficiencies in outbreak response [
6].
In developing countries, health security is a multifaceted issue that encompasses food security, global health threats, and the need for robust health systems [
7,
8]. These interrelated factors significantly influence both health outcomes and overall security. Although Indonesia, Cambodia, Vietnam, the Dominican Republic, and Ghana differ in geographic, economic, and sociopolitical contexts, they face similar challenges in strengthening their health security systems. In contrast, the Republic of Korea is recognized for its robust surveillance system and overall preparedness [
9]. This study aimed to evaluate and compare the health security and preparedness of Indonesia, Vietnam, the Dominican Republic, Cambodia, Ghana, and the Republic of Korea using e-SPAR and GHS index scores, with the goal of identifying key strengths and weaknesses and offering targeted recommendations to strengthen national preparedness and promote international collaboration for future health threats.
Materials and Methods
This study employed a comparative case study approach that integrated quantitative and qualitative analyses. Secondary data from e-SPAR (internal evaluation) scores and the GHS index (external evaluation) were used to assess health security and preparedness in 6 selected countries. The 2023 e-SPAR database was obtained from the WHO website [
5] and filtered to include reports from 5 low- and middle-income countries (LMICs)—3 Southeast Asian countries (Indonesia, Cambodia, and Vietnam), 1 Latin American country (the Dominican Republic), and 1 African country (Ghana). The selection criteria focused on countries with a strategic partnership with the Republic of Korea in terms of Official Development Assistance and on those represented by students in the Yonsei University School of Medicine’s Global Health Security Research Group. The Republic of Korea was included to represent a developed country, having achieved the No. 1 ranking in Bloomberg’s final tally for coronavirus disease 2019 (COVID-19) resilience.
Average scores for each country were summarized using descriptive statistics, with the lowest scores based on capacities and indicators identified. The GHS index scores for the 6 countries were obtained from the 2021 GHS index report [
6]. Descriptive statistics were then used to compare each country’s scores in various categories against the global average.
A strengths, weaknesses, opportunities, and threats (SWOT) analysis was conducted for each of the 5 LMICs (Indonesia, Cambodia, Vietnam, the Dominican Republic, and Ghana) to assess their current status in health security and preparedness. Strengths and weaknesses were sourced directly from the WHO e-SPAR database (2023). Opportunities were identified by selecting indicators with a minimum score of 75 (reflecting the range of the country with the highest overall health security index score) from the 2021 GHS index report, while threats were determined by identifying indicators with a score of 0 (mirroring the range of the country with the lowest score). Common features present in at least 3 countries were then highlighted through a collective SWOT analysis. Finally, the characteristics of the developing countries were compared with those of the Republic of Korea, and recommended strategies were proposed based on this analysis.
Results
The study examined 6 countries: 4 from Asia, 1 from Africa, and 1 from Latin America (
Table 1). Politically, the sample included 1 constitutional monarchy (parliamentary cabinet system), 4 republics (presidential systems), and 1 socialist republic (communist party system). Four countries had a gross domestic product per capita below 5,000 United States dollars (USD), 1 had approximately 10,000 USD, and 1 had around 30,000 USD. Four countries had populations under 50 million, 1 had about 100 million, and 1 had approximately 300 million. Technically, the 2024 global innovation index information and communications technology scores were 95 in the Republic of Korea, 76.7 in Indonesia, 70.6 in Vietnam, 59.3 in the Dominican Republic, 51.4 in Ghana, and 49.9 in Cambodia.
The overall average scores for the 15 IHR implementation capacities in 2023 were 99, 75, 68, 56, 54, and 52 for the Republic of Korea, Indonesia, Cambodia, Ghana, Vietnam, and the Dominican Republic, respectively (
Figure 1). Compared with the global average of 64, the scores for Indonesia, Cambodia, and the Republic of Korea were above average, whereas the other 3 countries remained below this threshold.
According to the 2021 GHS index report, the Republic of Korea, Indonesia, Vietnam, the Dominican Republic, Ghana, and Cambodia ranked 9th, 45th, 65th, 103rd, 104th, and 126th, respectively.
Figure 2 details the overall average scores and the 6 pillars of health security (prevent, detect, respond, health, norms, risks) for these countries. Indonesia’s overall score was 50.4, with the lowest score in the prevention category. The overall scores for Cambodia, Vietnam, the Dominican Republic, and Ghana were 31.1, 42.9, 34.5, and 34.3, respectively, with particularly low scores noted in the health system category.
Each country was analyzed individually using the SWOT framework, with the e-SPAR and GHS index data used to identify internal factors (strengths and weaknesses) and external factors (opportunities and threats) as shown in
Figure 3. Common features observed in at least 3 countries were then highlighted in a collective SWOT analysis. Surveillance (early warning and event management) emerged as the primary strength across most countries. Common opportunities included international commitments and robust immunization programs. In contrast, many countries exhibited weaknesses related to policy, legal, and normative frameworks for IHR implementation, as well as challenges in human resources, chemical event management, and radiation emergency preparedness. Recurring threats involved biosafety, biosecurity, dual-use research and the culture of responsible science, infection control practices, coordination between public health and security authorities, vulnerabilities in laboratory supply chains, and communication issues with healthcare workers during public health emergencies (
Figure 4).
Discussion
Figure 4 illustrates the main challenges and main strengths in every member state that submitted e-SPAR information to the WHO. The SWOT analysis of 6 countries found that common challenges in LMICs were policy, legal, and normative instruments to implement IHR, human resources, chemical events, and radiation emergencies, while common strengths were surveillance (early warning and event management). The GHS index (2021) was also analyzed for opportunities and threat analysis.
Based on the SWOT analysis, recommended strategies were developed to enhance GHS (
Figure 5). Among these, strengthening surveillance (i.e., early warning systems and event management, which includes verification, investigation, analysis and dissemination of information) through global collaboration emerged as the most promising strength-opportunity strategy for the 5 LMICs. This strategy is critical for managing transboundary diseases that affect human, animal, and environmental health. Integrating surveillance efforts across borders can lead to more efficient resource use, improved preparedness, and a robust response to emerging threats. Nevertheless, implementing such cooperative strategies poses challenges, including the uneven distribution of costs and benefits among participating countries. Global cooperative surveillance can optimize efficiency and resource allocation, with international partnerships enhancing the capacity to detect and respond to health events [
10]. Moreover, global surveillance networks—such as the Global Public Health Intelligence Network and HealthMap—play crucial roles in informing both national and transnational practices [
11]. Organizations like Connecting Organizations for Regional Disease Surveillance also highlight the importance of trust-based networks for sharing best practices and innovations in disease surveillance [
12]. Enhanced surveillance supports biosafety, biosecurity, and infection control by providing early detection, situational awareness, and data-driven decision-making. Integrating advanced technologies and methodologies is essential to confront the growing challenges posed by emerging infectious diseases, bioterrorism, and the global movement of people and goods.
Surveillance was found to be a main strength in the Republic of Korea, as shown by a perfect score from e-SPAR capacity and a high score in the Detecting and Reporting category of the GHS index. This performance is particularly notable in real-time One Health surveillance, reporting indicators, and data accessibility and transparency. The Republic of Korea’s health surveillance system, which is an advanced framework designed to monitor and manage public health threats effectively, integrates traditional surveillance methods with cutting-edge digital tools to enhance its capabilities in disease detection, monitoring, and response. For instance, its sentinel surveillance system for Hand, Foot, and Mouth Disease (HFMD), operational since 2009 in approximately 100 pediatric clinics nationwide, is crucial for tracking incidence trends and informing public health planning [
13]. Additionally, the Korean National Healthcare-associated Infections Surveillance System has significantly reduced central line-associated bloodstream infection rates across intensive care units, demonstrating the system’s effectiveness in infection control [
14]. During the COVID-19 pandemic, the Epidemiological Investigation Support System leveraged big data from cellular base stations, credit card transactions, and QR codes to track infected individuals, enhancing the speed and accuracy of epidemiological investigations [
15]. The National Health Insurance Claims-based Surveillance further complements conventional methods by using claims data to monitor disease incidence, thereby providing a stable measure of disease trends with fewer limitations than traditional reporting systems [
16]. The Republic of Korea’s comprehensive surveillance system represents a best practice that developing countries could adopt to improve their One Health approach.
Some limitations of this study should be acknowledged. Although e-SPAR provides the most recent official data reported directly to WHO headquarters to describe internal factors, and the GHS index offers current external evaluations, both data sources may not fully capture the present situation. Moreover, due to the challenges of assessing all 195 countries, the SWOT analysis based on these 6 countries may not be generalizable worldwide. Future studies should also investigate the underlying causes of the identified weaknesses and threats.
Conclusion
The SWOT analysis, based on e-SPAR and GHS index scores for Indonesia, Cambodia, Vietnam, the Dominican Republic, and Ghana, indicates that countries should prioritize enhancing surveillance capacity (including early warning functions and event management encompassing verification, investigation, analysis, and information dissemination) as an internal success factor, and improving the immunization indicator (encompassing vaccination rates for human and animal diseases and the national vaccine delivery system) as an external success factor. Consequently, nations should concentrate on 2 technical areas: early warning and event management, and national vaccine access and delivery.
Global collaboration—through building trust-based networks with developed countries such as the Republic of Korea, which possesses a comprehensive government surveillance system and immunization ecosystem that includes the International Vaccine Institute—can facilitate the sharing of best practices.
HIGHLIGHTS
• World Health Organization International Health Regulations capacities were generally low, with particular concerns about preparedness for chemical disasters, food safety, and cross-border infectious disease transmission.
• The study emphasized that surveillance capacity—as an internal factor (early warning and event management) —and the immunization indicator—as an external factor (vaccination rates for human and animal diseases, including the national vaccine delivery system) —are priority strategies for strengthening future prevention and detection systems.
• To effectively respond to global health threats, countries must focus on improving 2 technical areas (early warning and event management, and national vaccine access and delivery) using a One Health approach.
Article information
Ethics Approval
The informed consent was waived because of the retrospective nature of this study.
Conflicts of Interest
Chaeshin Chu has been the managing editor of Osong Public Health and Research Perspectives since October 2011. The other authors have no conflicts of interest to declare.
Authors’ Contributions
Conceptualization: MY, NF, OKA; Data curation: NF, TLNN, DIJB; Formal analysis: all authors; Investigation: all authors; Methodology: MY, NF, OKA; Project administration: NF, VP; Supervision: MY, CC; Validation: CC; Visualization: NF, MY; Writing–original draft: NF, MY; Writing–review & editing: all authors. All authors read and approved the final manuscript.
Acknowledgements
We would like to express our heartfelt gratitude to Director Hyejin Jung and Assistant Manager Hayoung Kim of KOFIH (Korea Foundation for International Healthcare) LEE Jong-wook Academy for their invaluable support in providing the Infectious Disease Specialist Course (Epidemiology). We would like to thank Prof. Sunjoo Kang and Prof. Whiejong Han from Global Health Department of Yonsei University Graduate School of Public Health for allowing KOICA (Korea International Cooperation Agency)-Yonsei Master’s Degree Program Students to participate in this study. We also sincerely appreciate to Prof. Tai-Soon Yong, Prof. Soon-Jung Park, Prof. Hyung-Pyo Kim, Prof. Myeong-Heon Shin and Prof. Ju Yeong Kim from the Institute of Tropical Medicine of the Yonsei University College of Medicine for supporting Global Health Security Research Meeting.
Figure 3.
SWOT analysis of health security in 5 selected low- and middle-income countries using e-SPAR and GHS index.
IHR, International Health Regulations; IPC, infection prevention and control; PoE, point of entry; JEE, Joint External Evaluation; PVS, Performance Veterinary Service; SWOT, strengths, weaknesses, opportunities, and threats; e-SPAR, electronic State Party Self-Assessment Annual Reporting mechanism; GHS, global health security.
, Nuha Fairusya2
