Leveraging collaborative research networks against antimicrobial resistance in Asia.

Background: Antimicrobial resistance (AMR) is a global health security threat requiring research collaboration globally and regionally. Despite repeated calls for international research collaboration in Asia, literature analyzing the nature of collaborative AMR research in Asia has been sparse. This study aims to describe the characteristics of the AMR research network in Asia and investigate the factors influencing collaborative tie formation between organizations. Methods: We carried out a mixed-methods study by combining social network analysis (SNA) and in-depth interviews. SNA was first conducted on primary data to describe the characteristics of the AMR research network in Asia. Exponential random graph models (ERGMs) were then used to examine the influence of factors such as organization type, country affluence levels, regional proximity and One Health research on collaborative tie formation among organizations. In-depth interviews were conducted with network participants to provide contextual insights to the quantitative data. Results: The results reveal that the research network exhibits a core-periphery structure, where a minority of organizations have a significantly higher number of collaborations with others. The most influential organizations in the network are academic institutions from high-income countries within and outside Asia. The ERGM results demonstrate that organizations prefer to collaborate with others of similar organization types, country-based affluence levels and One Health domains of focus, but also with others across different World Health Organization regions. The qualitative analysis identified three main themes: the challenges that impede collaboration, the central role of academic institutions, and the nature of collaborations across One Health domains, giving rise to important empirical milestones in understanding AMR research in Asia. Conclusion: We thus recommend leveraging academic institutions as "integrators" to bridge differences, increasing funds channelled towards research capacity building to alleviate structural barriers to collaboration, streamlining collaborative mechanisms to overcome cumbersome administrative hurdles, and increasing efforts to establish trust between all organizations.

Health financing policies during the COVID-19 pandemic and implications for universal health care: a case study of 15 countries.

BACKGROUND: The COVID-19 pandemic was a health emergency requiring rapid fiscal resource mobilisation to support national responses. The use of effective health financing mechanisms and policies, or lack thereof, affected the impact of the pandemic on the population, particularly vulnerable groups and individuals. We provide an overview and illustrative examples of health financing policies adopted in 15 countries during the pandemic, develop a framework for resilient health financing, and use this pandemic to argue a case to move towards universal health coverage (UHC). METHODS: In this case study, we examined the national health financing policy responses of 15 countries, which were purposefully selected countries to represent all WHO regions and have a range of income levels, UHC index scores, and health system typologies. We did a systematic literature review of peer-reviewed articles, policy documents, technical reports, and publicly available data on policy measures undertaken in response to the pandemic and complemented the data obtained with 61 in-depth interviews with health systems and health financing experts. We did a thematic analysis of our data and organised key themes into a conceptual framework for resilient health financing. FINDINGS: Resilient health financing for health emergencies is characterised by two main phases: (1) absorb and recover, where health systems are required to absorb the initial and subsequent shocks brought about by the pandemic and restabilise from them; and (2) sustain, where health systems need to expand and maintain fiscal space for health to move towards UHC while building on resilient health financing structures that can better prepare health systems for future health emergencies. We observed that five key financing policies were implemented across the countries-namely, use of extra-budgetary funds for a swift initial response, repurposing of existing funds, efficient fund disbursement mechanisms to ensure rapid channelisation to the intended personnel and general population, mobilisation of the private sector to mitigate the gaps in public settings, and expansion of service coverage to enhance the protection of vulnerable groups. Accountability and monitoring are needed at every stage to ensure efficient and accountable movement and use of funds, which can be achieved through strong governance and coordination, information technology, and community engagement. INTERPRETATION: Our findings suggest that health systems need to leverage the COVID-19 pandemic as a window of opportunity to make health financing policies robust and need to politically commit to public financing mechanisms that work to prepare for future emergencies and as a lever for UHC. FUNDING: Bill & Melinda Gates Foundation.

A qualitative exploration of factors that influence the uptake of tuberculosis services by low-skilled migrant workers in Singapore.

INTRODUCTION: Singapore relies heavily on migrant workers to build its country and harbours a relatively large population of these workers. Importantly, tuberculosis (TB) remains a pernicious threat to the health of these workers and in line with the United Nations High-Level Meeting in 2023, this paper aims to uncover the qualitative discourse facing migrant workers' uptake of TB services and provide policy recommendations to enable more equitable access to TB services for this population. METHODS: In-depth interviews were carried out with the migrant worker population recruited from a non-governmental organisation in Singapore that serves migrant workers through the provision of primary healthcare services, counselling, and social assistance. Interviews stopped once thematic saturation was achieved and no new themes and subthemes were found. RESULTS: A total of 29 participants were interviewed, including 16 Bangladeshis and 13 Chinese, aged between 22 and 54 years old, all worked in the construction sector. Four key themes emerged. They are (1) General TB knowledge: Misconceptions are prevalent, where we found that participants were aware of the disease but did not possess a clear understanding of its pathophysiology and associated health effects, (2) Contextual knowledge and perception of associated policies related to TB in Singapore: low awareness among migrant workers as participants' accounts depicted a lack of information sources in Singapore especially on issues related to healthcare including TB, (3) Attitude to towards TB: Motivation to seek treatment is underpinned by ability to continue working and (4) Stigma: mixed perception of how society views TB patients. The gaps identified in migrant workers' TB knowledge, their attitude towards the disease and their perception of the availability of TB-related services is despite Singapore's efforts to curb community spread of TB and its proactive initiatives to reduce the prevalence. CONCLUSION: Our study illuminates the various aspects that policymakers need to home in on to ensure this vulnerable group is sufficiently supported and equitably cared for if they develop active TB during their stay in Singapore as they contribute to the nation's economy. Leveraging the COVID-19 pandemic as a window of opportunity to improve overall healthcare access for vulnerable groups in Singapore can be a starting point.

A Qualitative Study on the Implementation of the National Action Plan on Antimicrobial Resistance in Singapore.

Antimicrobial resistance (AMR) is a global public health threat that affects humans, animals, and the environment across the One Health spectrum. Singapore launched its own National Strategic Action Plan (NSAP) on AMR in 2017 with the aim of tackling the growing threat of AMR in Singapore through coordinated approaches. However, little is known about the implementation of the NSAP. In this study, we analysed the implementation of the NSAP with guidance from an AMR governance framework. We conducted in-depth interviews with 20 participants across the One Health spectrum. The interviews were transcribed verbatim and analysed thematically. Overall, the implementation of activities against AMR was more advanced with respect to human health compared to other sectors such as (1) AMR and antimicrobial use (AMU) surveillance systems in hospitals; (2) the hospital antimicrobial stewardship (AMS) service and legislation to optimise AMU; (3) the national children and adults vaccination programme for IPC; (4) multiple avenues for education and awareness for both professionals and public; and (5) extensive research and collaboration networks with many sources of funding. Areas that were lacking presented problems including (1) an incomplete surveillance system for AMR and AMU across all sectors; (2) the need for better AMS and legislation in some sectors; (3) insufficient innovation in education for sustained behavioural modification; and (4) the need for more open research collaborations and the translation of research into policy outcomes. Improvements in these areas will enhance the overall implementation of the NSAP through a more holistic One Health approach.

A Qualitative Study on the Policy Process and Development of the National Action Plan on Antimicrobial Resistance in Singapore.

The global public health threat of antimicrobial resistance (AMR) has been accelerated by many interrelated factors spanning across One Health-human health, animal health, and the environment. Singapore launched its own National Strategic Action Plan (NSAP) on AMR in November 2017 with the aim of tackling the growing threat of AMR in Singapore through coordinated approaches. However, little is known about the policy process and development of the NSAP in Singapore. In this study, we analysed these aspects using an AMR governance framework. In-depth interviews were conducted with 20 participants across the One Health spectrum. The interviews were transcribed verbatim and analysed thematically. Areas that were well executed included (1) good coordination across various agencies, (2) a dedicated office to coordinate the work on the NSAP, and (3) a high level of governmental support. Areas that were lacking included (1) a lack of participation from certain sectors, (2) insufficient awareness around the AMR issue, (3) constraints in information sharing, and (4) a lack of ideal indicators to track the progress in addressing AMR. Improvements in these areas will provide a more holistic One Health engagement in support of the effective planning and implementation of the NSAP.

Mitigating the impacts of the COVID-19 pandemic on vulnerable populations: Lessons for improving health and social equity.

The COVID-19 pandemic had an inequitable and disproportionate impact on vulnerable populations, reversing decades of progress toward healthy populations and poverty alleviation. This study examines various programmatic tools and policy measures used by governments to support vulnerable populations during the pandemic. A comparative case study of 15 countries representing all World Health Organization's regions offers a comprehensive picture of countries with varying income statuses, health system arrangements and COVID-19 public health measures. Through a systematic desk review and key informant interviews, we report a spectrum of mitigation strategies deployed in these countries to address five major types of vulnerabilities (health, economic, social, institutional and communicative). We found a multitude of strategies that supported vulnerable populations such as migrant workers, sex workers, prisoners, older persons and school-going children. Prioritising vulnerable populations during the early phase of COVID-19 vaccination campaigns, direct financial subsidies and food assistance programmes were the most common measures reported. Additionally, framing public health information and implementing culturally sensitive health promotion interventions helped bridge the communication barriers in certain instances. However, these measures remain insufficient to protect vulnerable populations comprehensively. Our findings point to the need to expand fiscal space for health, enlarge healthcare coverage, incorporate equity principles in all policies, leverage technology, multi-stakeholder co-production of policies and tailored community engagement mechanisms.

Communicating risk during early phases of COVID-19: Comparing governing structures for emergency risk communication across four contexts.

Background: Emergency risk communication (ERC) is key to achieving compliance with public health measures during pandemics. Yet, the factors that facilitated ERC during COVID-19 have not been analyzed. We compare ERC in the early stages of the pandemic across four socio-economic settings to identify how risk communication can be improved in public health emergencies (PHE). Methods: To map and assess the content, process, actors, and context of ERC in Germany, Guinea, Nigeria, and Singapore, we performed a qualitative document review, and thematically analyzed semi-structured key informant interviews with 155 stakeholders involved in ERC at national and sub-national levels. We applied Walt and Gilson's health policy triangle as a framework to structure the results. Results: We identified distinct ERC strategies in each of the four countries. Various actors, including governmental leads, experts, and organizations with close contact to the public, collaborated closely to implement ERC strategies. Early integration of ERC into preparedness and response plans, lessons from previous experiences, existing structures and networks, and clear leadership were identified as crucial for ensuring message clarity, consistency, relevance, and an efficient use of resources. Areas of improvement primarily included two-way communication, community engagement, and monitoring and evaluation. Countries with recurrent experiences of pandemics appeared to be more prepared and equipped to implement ERC strategies. Conclusion: We found that considerable potential exists for countries to improve communication during public health emergencies, particularly in the areas of bilateral communication and community engagement as well as monitoring and evaluation. Building adaptive structures and maintaining long-term relationships with at-risk communities reportedly facilitated suitable communication. The findings suggest considerable potential and transferable learning opportunities exist between countries in the global north and countries in the global south with experience of managing outbreaks.

Austerity Measures and Underfunding of the Spanish Health System during the COVID-19 Pandemic-Perception of Healthcare Staff in Spain.

Insufficient pandemic preparedness and underfunding of human and economic resources have conditioned the response to COVID-19 in Spain. This underfunding has continued since the austerity measures introduced during the 2008 financial crisis. This study aims to understand the perceptions of healthcare staff in Spain on the relationship between the funding of the health system and its capacity to respond to the COVID-19 pandemic. To this end, we carried out a thematic content analysis, based on 79 online semi-structured interviews with healthcare staff across the regions most affected by the COVID-19 first wave. Participants reported a lack of material resources, which had compromised the capacity of the health system before the pandemic. The lack of human resources was to be addressed by staff reorganisation, such as reinforcing hospital units to the detriment of primary health care. Staff shortages continued straining the COVID-19 response, even after material scarcities were later partially alleviated. Personnel shortages need to be adequately addressed in order to adequately respond to future health crises.

Post-intervention acceptability of multicomponent intervention for management of hypertension in rural Bangladesh, Pakistan, and Sri Lanka- a qualitative study.

BACKGROUND: COBRA-BPS (Control of Blood Pressure and Risk Attenuation-Bangladesh, Pakistan, Sri Lanka), a multicomponent, community health-worker (CHW)-led hypertension management program, has been shown to be effective in rural communities in South Asia. This paper presents the acceptability of COBRA-BPS multicomponent intervention among the key stakeholders. METHODS: We conducted post-implementation interviews of 87 stakeholder including 23 community health workers (CHWs), 19 physicians and 45 patients in 15 rural communities randomized to COBRA-BPS multicomponent intervention in in Bangladesh, Pakistan, and Sri Lanka. We used Theoretical Framework for Acceptability framework (TFA) with a focus on affective attitude, burden, ethicality, intervention coherence, opportunity cost, perceived effectiveness and self-efficacy. RESULTS: COBRA-BPS multicomponent intervention was acceptable to most stakeholders. Despite some concerns about workload, most CHWs were enthusiastic and felt empowered. Physicians appreciated the training sessions and felt trusted by their patients. Patients were grateful to receive the intervention and valued it. However, patients in Pakistan and Bangladesh expressed the need for supplies of free medicines from the primary health facilities, while those in Sri Lanka were concerned about supplies' irregularities. All stakeholders favoured scaling-up COBRA-BPS at a national level. CONCLUSIONS: COBRA-BPS multicomponent intervention is acceptable to the key stakeholders in Bangladesh, Pakistan and Sri Lanka. Community engagement for national scale-up of COBRA-BPS is likely to be successful in all three countries.

COVID-19 public health and social measures: a comprehensive picture of six Asian countries.

The COVID-19 pandemic will not be the last of its kind. As the world charts a way towards an equitable and resilient recovery, Public Health and Social Measures (PHSMs) that were implemented since the beginning of the pandemic need to be made a permanent feature of health systems that can be activated and readily deployed to tackle sudden surges in infections going forward. Although PHSMs aim to blunt the spread of the virus, and in turn protect lives and preserve health system capacity, there are also unintended consequences attributed to them. Importantly, the interactions between PHSMs and their accompanying key indicators that influence the strength and duration of PHSMs are elements that require in-depth exploration. This research employs case studies from six Asian countries, namely Indonesia, Singapore, South Korea, Thailand, the Philippines and Vietnam, to paint a comprehensive picture of PHSMs that protect the lives and livelihoods of populations. Nine typologies of PHSMs that emerged are as follows: (1) physical distancing, (2) border controls, (3) personal protective equipment requirements, (4) transmission monitoring, (5) surge health infrastructure capacity, (6) surge medical supplies, (7) surge human resources, (8) vaccine availability and roll-out and (9) social and economic support measures. The key indicators that influence the strength and duration of PHSMs are as follows: (1) size of community transmission, (2) number of severe cases and mortality, (3) health system capacity, (4) vaccine coverage, (5) fiscal space and (6) technology. Interactions between PHSMs can be synergistic or inhibiting, depending on various contextual factors. Fundamentally, PHSMs do not operate in silos, and a suite of PHSMs that are complementary is required to ensure that lives and livelihoods are safeguarded with an equity lens. For that to be achieved, strong governance structures and community engagement are also required at all levels of the health system.