Kiesha Prem

Background: Strategic health purchasing is a critical lever for advancing universal health coverage (UHC), particularly in low- and middle-income countries (LMICs). Across Southeast Asia, countries are reforming their purchasing functions to enhance the efficiency, equity, and quality of primary healthcare (PHC). This study assesses the extent and progress of strategic purchasing for PHC in four Association of Southeast Asian Nations (ASEAN) member states: Indonesia, the Philippines, Thailand, and Vietnam. Methods: We applied the Strategic Health Purchasing Progress Tracking Framework to conduct a structured comparative assessment across five purchasing dimensions: financial management, benefits specification, contracting arrangements, provider payment, and performance monitoring. Data was collected through semi-structured interviews with national stakeholders, supplemented by grey literature and policy document reviews. The data was analysed, triangulated and validated through expert consultation and thematic analysis. Results: All four countries have taken steps toward institutionalising strategic purchasing through national health insurance (NHI) schemes, though the depth and coherence of reforms vary. Thailand’s universal coverage scheme (UCS) demonstrates the most advanced implementation, characterised by performance-based payment mechanisms and relatively strong monitoring systems. Indonesia and the Philippines are implementing pilots to align payments with service delivery goals, though challenges persist in integrating PHC with broader health system functions. Vietnam maintains high insurance coverage but exhibits limited strategic purchasing practices, particularly for PHC. Across all countries, gaps in data systems and governance capacity constrain effective implementation. Conclusion: Strategic purchasing reforms in Southeast Asia are progressing but remain uneven in scope and institutional maturity. Strengthening policy coherence, investing in health information systems and aligning public financing with PHC priorities will be critical to advancing these reforms. In particular, Thailand’s experience offers relevant lessons for broader regional efforts to operationalise strategic purchasing for more resilient and equitable PHC systems.

Background: Private pharmacies are the primary access point for antibiotics in Lao PDR, yet they are frequently implicated in the unregulated dispensing that drives antimicrobial resistance. Regulatory non-compliance is often attributed to professional negligence, ignoring the structural constraints of the private sector.Methods: A mixed-methods assessment of 32 private pharmacies across three representative provinces of Lao PDR, combining physicochemical analysis of antibiotic quality, standardized Good Pharmacy Practice (GPP) audits, and in-depth semi-structured interviews. The triangulated design enabled comparisons across objective supply chain quality with provider knowledge and dispensing behaviors.Findings: Our inventory audit (n=689) revealed a high prevalence of “Watch List” antibiotics (31.7%), unregistered formulations (14.7%), coupled with widespread GPP noncompliance (100%). Class 2 pharmacies had a higher rate of unregistered antibiotics than Class 1 (IRR:1.69, 95% CI:1.02–2.79). Qualitative analysis identified two themes that explained these failures. First, a translational gap exists where frontline providers lack familiarity with core stewardship terminology (e.g., “antimicrobial”), limiting engagement with national policy. Second, pharmacists systematically dispense sub-therapeutic doses or unregistered generics to accommodate patient purchasing power.Interpretation: Private pharmacies in Lao PDR operate under a dual burden of terminological disconnection and economic precarity. Our findings suggest that regulatory enforcement alone is insufficient to address the moral hazard faced by pharmacists who must choose between dispensing improper regimens or denying primary care. Effective stewardship requires re-engineering educational curricula to bridge the translational gap and implementing financial protection mechanisms to reduce the economic pressure for irrational dispensing.

Background: The ongoing 2023–2024 mpox outbreak in several African countries, driven by the novel Clade Ib strain, has resulted in imported cases reported in Sweden, Thailand, and India. The potentially high transmissibility of this new strain and shifts in transmission modes may make territories in Asia, which were minimally affected by previous mpox waves, susceptible to community-wide transmission following importation. While this highlights the importance of early preparedness, current knowledge of the virus’s transmission dynamics remains too limited to effectively inform policy-making and resource planning. Methods: A compartmental model was constructed to characterise the potential mpox transmission dynamics. Importation-triggered outbreaks were simulated in 37 Asian cities under scenarios with one, three, and five initial local infections. The impacts of various non-pharmaceutical interventions (NPIs), including isolation and quarantine, were projected and compared. Findings: Our simulations revealed substantial disparities in outbreak sizes among the 37 Asian cities, with large-scale outbreaks expected in territories with a high proportion of sexually active individuals at risk or low immunity from smallpox vaccination. Total case count in one year following initial local infections would increase linearly with initial infection size. In the scenario with three initial local infections, up to 340 cases per million residents were expected without interventions. Isolation for diagnosed cases was projected to lower the outbreak size by 43.8% (interquartile range [IQR]: 42.7%–44.5%), 67.8% (IQR: 66.5%–68.9%), 80.8% (IQR: 79.5%–82.0%), and 88.0% (IQR: 86.8%–89.1%) when it reduced interpersonal contacts by 25%, 50%, 75%, and 100%, respectively. Quarantining close contacts would contribute to a further decrease in cases of up to 22 percentage points over one year. Interpretation: The potential mpox outbreak in an Asian setting could be alleviated through strong surveillance and timely response from stakeholders. NPIs are recommended for outbreak management due to their demonstrated effectiveness and practicability. KEY MESSAGES: What is already known on this topic: Clade Ib monkeypox virus (MPXV) is circulating in the Democratic Republic of the Congo (DRC) and its neighbouring countries, with imported cases being identified globally. Meanwhile, evidence indicates that the virus can be transmitted through both sexual and non-sexual routes, raising concerns about its potential spread in the general population. To prevent a global outbreak, the World Health Organization (WHO) suggested countries around the globe to prepare in advance. What this study adds: Our simulations quantified the potential disease burden of an mpox outbreak triggered by a once-time importation event in 37 major Asian cities with varying pre-existing immunity levels and populations at higher risk due to frequent sexual activities. The compartmental modelling framework developed in this study also projected the effectiveness of diverse non-pharmaceutical intervention (NPI) strategies in outbreak control, providing policy-makers with guidance for effective public health crisis management. How this study might affect research, practice or policy: An importation-triggered mpox outbreak can be substantially mitigated with powerful disease surveillance and a prompt response of the stakeholders, but may also lead to severe consequences with high morbidity and mortality if not addressed in time in cities with a large highly sexually active population. Various NPIs, particularly isolating infected cases, are recommended for curbing the disease outbreak due to their feasibility and effectiveness in the Asian setting.

Initial investigation into the emerging mpox outbreak of novel clade Ib in eastern Democratic Republic of the Congo has identified signs of sustained human-to-human transmission and epidemiological links to sexual contacts involving female sex workers (FSWs) ¹ , which have not been observed in previous clade Ia outbreaks. Using mathematical models incorporating age-dependent contact patterns, we quantified the role of frequent sexual interactions as opposed to community contacts in clade Ib’s dynamics and found that this additional mode of transmission could explain its increased outbreak potential compared with clade Ia. As with the globally-circulating clade IIb, transmitted predominantly among men who have sex with men ² , our findings reinforce the importance of protecting key population groups, specifically FSWs for clade Ib, in controlling ongoing mpox outbreaks.

Background The COVID-19 pandemic both relied and placed significant burdens on the experts involved from research and public health sectors. The sustained high pressure of a pandemic on responders, such as healthcare workers, can lead to lasting psychological impacts including acute stress disorder, post-traumatic stress disorder, burnout, and moral injury, which can impact individual wellbeing and productivity. Methods As members of the infectious disease modelling community, we convened a reflective workshop to understand the professional and personal impacts of response work on our community and to propose recommendations for future epidemic responses. The attendees represented a range of career stages, institutions, and disciplines. This piece was collectively produced by those present at the session based on our collective experiences. Results Key issues we identified at the workshop were lack of institutional support, insecure contracts, unequal credit and recognition, and mental health impacts. Our recommendations include rewarding impactful work, fostering academia-public health collaboration, decreasing dependence on key individuals by developing teams, increasing transparency in decision-making, and implementing sustainable work practices. Conclusions Despite limitations in representation, this workshop provided valuable insights into the UK COVID-19 modelling experience and guidance for future public health crises. Recognising and addressing the issues highlighted is crucial, in our view, for ensuring the effectiveness of epidemic response work in the future.

Background: To eliminate cervical cancer as a public health problem, the World Health Organization had recommended routine vaccination of adolescent girls with two doses of the human papillomavirus (HPV) vaccine before sexual initiation. However, many countries have yet to implement HPV vaccination because of financial or logistical barriers to delivering two doses outside the infant immunisation programme. Methods: Using three independent HPV transmission models, we estimated the long-term health benefits and cost-effectiveness of one-dose versus two-dose HPV vaccination, in 188 countries, under scenarios in which one dose of the vaccine gives either a shorter duration of full protection (20 or 30 years) or lifelong protection but lower vaccine efficacy (e.g. 80%) compared to two doses. We simulated routine vaccination with the 9-valent HPV vaccine in 10-year-old girls at 80% coverage for the years 2021–2120, with a 1-year catch-up campaign up to age 14 at 80% coverage in the first year of the programme. Results: Over the years 2021–2120, one-dose vaccination at 80% coverage was projected to avert 115.2 million (range of medians: 85.1–130.4) and 146.8 million (114.1–161.6) cervical cancers assuming one dose of the vaccine confers 20 and 30 years of protection, respectively. Should one dose of the vaccine provide lifelong protection at 80% vaccine efficacy, 147.8 million (140.6–169.7) cervical cancer cases could be prevented. If protection wanes after 20 years, 65 to 889 additional girls would need to be vaccinated with the second dose to prevent one cervical cancer, depending on the epidemiological profiles of the country. Across all income groups, the threshold cost for the second dose was low: from 1.59 (0.14–3.82) USD in low-income countries to 44.83 (3.75–85.64) USD in high-income countries, assuming one dose confers 30-year protection. Conclusions: Results were consistent across the three independent models and suggest that one-dose vaccination has similar health benefits to a two-dose programme while simplifying vaccine delivery, reducing costs, and alleviating vaccine supply constraints. The second dose may become cost-effective if there is a shorter duration of protection from one dose, cheaper vaccine and vaccination delivery strategies, and high burden of cervical cancer.