Breast cancer in Thailand: policy and health system challenges to universal healthcare.

Thailand has successfully implemented Universal Health Coverage (UHC) and embedded the 2030 Agenda for Sustainable Development into its Thailand 4.0 policy. Breast cancer is a growing challenge in Thailand, as it is globally. It serves as a perfect medium through which to interrogate UHC and demonstrate areas of the health system which require further strengthening if UHC is to be sustainable in the longer term. We conducted a situation analysis and used a Systemic Rapid Assessment (SYSRA) framework to examine the challenges posed to UHC through the lens of breast cancer. We identified a number of challenges facing UHC including (1) continued political commitment; (2) the need for coordinated scale-up of strategic investments involving increased financing and fine-tuning of the allocation of resources according to health needs; (3) reducing inequities between health insurance schemes; (4) investing in innovation of technologies, and more critically, in technology transfer and capacity building; (5) increasing capacity, quality and confidence in the whole primary healthcare team but especially family medicine doctors. This would subsequently increase both efficiency and effectiveness of the patient pathway, as well as allow patients wherever possible to be treated close to their homes, work and family; (6) developing and connecting information systems to facilitate understanding of what is working, where needs are and track trends to monitor improvements in patient care. Our findings add to an existing body of evidence which suggest, in light of changing disease burden and increasing costs of care, a need for broader health system reforms to create a more enabling platform for integrated healthcare as opposed to addressing individual challenging elements one vertical system at a time. As low- and middle-income countries look to realize the 2015 Sustainable Development Goals and sustainable UHC this analysis may provide input for policy discussion at national, regional and community levels and have applicability beyond breast cancer services alone and beyond Thailand.

Surveillance and characterisation of influenza viruses among patients with influenza-like illness in Bali, Indonesia, July 2010-June 2014.

BACKGROUND: Although Indonesia has high fatality rate of human A/H5N1 cases, epidemiological and clinical data on influenza virus circulation among humans has been limited. Within Indonesia, Bali province is of interest due to high population densities of humans, pigs and poultry. This study aims to characterize and compare the epidemiological and clinical patterns of influenza viruses in humans through surveillance among patients with influenza-like illness (ILI) in Bali, Indonesia. METHODS: ILI patients were recruited at 21 sentinel health facilities across all nine regencies in Bali, from July 2010 to June 2014. PCR-based assays were used for detection and subtyping of influenza viruses. Demographic, behavioural and clinical data were tested for associations with influenza using chi-squared tests and logistic regression. RESULTS: Of 2077 ILI patients, 291 (14.0%) tested positive for influenza A, 152 (7.3%) for influenza B, and 16 (0.77%) for both influenza A and B. Of the influenza A isolates, the majority 61.2% were A/H3N2, followed by A/H1N1-pdm09 (80; 26.1%). Two A/H5N1 were identified. Influenza positive rates were significantly higher during wet season months (28.3%), compared with the dry season (13.8%; χ2 = 61.1; df = 1; p < 0.0001). Clinical predictors for infection varied by virus type, with measured fever (≥38 °C) more strongly associated with influenza B (AOR: 1.62; 95% CI: 1.10, 2.39). CONCLUSION: Influenza circulates year-round among humans in Bali with higher activity during the wet season. High contact rates with poultry and pigs, along with influenza virus detection that could not be subtyped through conventional assays, highlight the need for molecular studies to characterize epidemiological and evolutionary dynamics of influenza in this setting.

Sharing public health data and information across borders: lessons from Southeast Asia.

BACKGROUND: The importance of data and information sharing for the prevention and control of infectious diseases has long been recognised. In recent years, public health emergencies such as avian influenza, drug-resistant malaria, and Ebola have brought renewed attention to the need for effective communication channels between health authorities, particularly in regional contexts where neighbouring countries share common health threats. However, little empirical research has been conducted to date to explore the range of factors that may affect the transfer, exchange, and use of public health data and expertise across borders, especially in developing contexts. METHODS: To explore these issues, 60 interviews were conducted with domestic and international stakeholders in Cambodia and Vietnam, selected amongst those who were involved in regional public health programmes and networks. Data analysis was structured around three categories mapped across the dataset: (1) the nature of shared data and information; (2) the nature of communication channels; and (3) how information flow may be affected by the local, regional, and global system of rules and arrangements. RESULTS: There has been a great intensification in the circulation of data, information, and expertise across borders in Southeast Asia. However, findings from this study document ways in which the movement of data and information from production sites to other places can be challenging due to different standards and practices, language barriers, different national structures and rules that govern the circulation of health information inside and outside countries, imbalances in capacities and power, and sustainability of financing arrangements. CONCLUSIONS: Our study highlights the complex socio-technical nature of data and information sharing, suggesting that best practices require significant involvement of an independent third-party brokering organisation or office, which can redress imbalances between country partners at different levels in the data sharing process, create meaningful communication channels and make the most of shared information and data sets.

Seroprevalence and awareness of porcine cysticercosis across different pig production systems in south-central Cambodia.

BACKGROUND: Taeniasis/cysticercosis, caused by the pork tapeworm Taenia solium, represents an important public health and economic burden in endemic countries. However, there is a paucity of data on infection among pigs in many parts of Southeast Asia, particularly Cambodia. We aimed to estimate seroprevalence of porcine cysticercosis, and investigate husbandary practices and knowledge of the disease among livestock workers, across different pig sector units in south-central Cambodia. METHODS: A cross sectional survey was conducted among pig smallholders, commercial farms, slaughterhouses and traders/middlemen from south-central Cambodia, selected through multistage sampling in proportion to local pig populations sizes. Questionnaires were administered to 163 pig workers to obtain data pig production, trading and slaughtering practices. Sera from 620 pigs were tested for Taenia antigens using a commercial ELISA-based test. Associations between seroprevalence and pig husbandry practices were assessed using generalised linear mixed models, adjusting for random-effects at herd-level. RESULTS: Of 620 pigs sampled, 29 (4.7%) tested positive for Taenia antigens. Seropositivity was associated with type of pig sector unit (P = 0.008), with the highest seroprevalence among pigs sampled from traders/middlemen (16.7%; 95% CI: 4.4%-37.8%), smallholders (7.6%; 95% CI: 3.8%-14.1%) and slaughterhouses (4.1%; 95% CI: 2.0%-7.5%), while none of the pigs sampled from small/medium or large commercial farms tested positive. Although the vast majority of pigs were penned, practices that might facilitate human-to-pig transmission, such as use of household waste and surface water sources to feed pigs, were prevalent among smallholders. However these were not found to be significantly associated with infection. Of 163 interviewed pig workers, 115 (70.5%) were aware of porcine cysticercosis, and 78 (47.8%) also knew it could affect humans. Twenty-six (16.0%) reported having noticed lesions typical of cysticercosis in their pigs. CONCLUSIONS: Despite most pigs being kept confined in pens rather than raised in free-roaming systems, porcine cysticercosis appears to be endemic in south-central Cambodia and is associated with smallholder production. Further investigation is needed to identify which Taenia species are causing infections among pigs, and how seroprevalence and zoonotic risk may vary across the country, to understand the risks to public health and assess where interventions might be needed.

Designing evaluation studies to optimally inform policy: what factors do policy-makers in China consider when making resource allocation decisions on healthcare worker training programmes?

BACKGROUND: In light of the gap in evidence to inform future resource allocation decisions about healthcare provider (HCP) training in low- and middle-income countries (LMICs), and the considerable donor investments being made towards training interventions, evaluation studies that are optimally designed to inform local policy-makers are needed. The aim of our study is to understand what features of HCP training evaluation studies are important for decision-making by policy-makers in LMICs. We investigate the extent to which evaluations based on the widely used Kirkpatrick model - focusing on direct outcomes of training, namely reaction of trainees, learning, behaviour change and improvements in programmatic health indicators - align with policy-makers' evidence needs for resource allocation decisions. We use China as a case study where resource allocation decisions about potential scale-up (using domestic funding) are being made about an externally funded pilot HCP training programme. METHODS: Qualitative data were collected from high-level officials involved in resource allocation at the national and provincial level in China through ten face-to-face, in-depth interviews and two focus group discussions consisting of ten participants each. Data were analysed manually using an interpretive thematic analysis approach. RESULTS: Our study indicates that Chinese officials not only consider information about the direct outcomes of a training programme, as captured in the Kirkpatrick model, but also need information on the resources required to implement the training, the wider or indirect impacts of training, and the sustainability and scalability to other settings within the country. In addition to considering findings presented in evaluation studies, we found that Chinese policy-makers pay close attention to whether the evaluations were robust and to the composition of the evaluation team. CONCLUSIONS: Our qualitative study indicates that training programme evaluations that focus narrowly on direct training outcomes may not provide sufficient information for policy-makers to make decisions on future training programmes. Based on our findings, we have developed an evidence-based framework, which incorporates but expands beyond the Kirkpatrick model, to provide conceptual and practical guidance that aids in the design of training programme evaluations better suited to meet the information needs of policy-makers and to inform policy decisions.

Are scientific research outputs aligned with national policy makers' priorities? A case study of tuberculosis in Cambodia.

With funding for tuberculosis (TB) research decreasing, and the high global disease burden persisting, there are calls for increased investment in TB research. However, justification of such investments is questionable, when translation of research outputs into policy and health care improvements remains a challenge for TB and other diseases. Using TB in Cambodia as a case study, we investigate how evidence needs of national policy makers are addressed by topics covered in research publications. We first conducted a systematic review to compile all studies on TB in Cambodia published since 2000. We then identified priority areas in which evidence for policy and programme planning are required from the perspective of key national TB control stakeholders. Finally, results from the literature review were analysed in relation to the priority research areas for national policy makers to assess overlap and highlight gaps in evidence. Priority research areas were: TB-HIV co-infection; childhood TB; multidrug resistant TB (MDR-TB); and universal and equitable access to quality diagnosis and treatment. On screening 1687 unique papers retrieved from our literature search, 253 were eligible publications focusing on TB in Cambodia. Of these, only 73 (29%) addressed one of the four priority research areas. Overall, 30 (11%), five (2%), seven (2%) and 37 (14%) studies reported findings relevant to TB-HIV, childhood TB, MDR-TB and access to quality diagnosis and treatment respectively. Our analysis shows that a small proportion of the research outputs in Cambodia address priority areas for informing policy and programme planning. This case study illustrates that there is substantial room for improvement in alignment between research outputs and evidence gaps that national policy makers would like to see addressed; better coordination between researchers, funders and policy makers' on identifying priority research topics may increase the relevance of research findings to health policies and programmes.

A strong TB programme embedded in a developing primary healthcare system is a lose-lose situation: insights from patient and community perspectives in Cambodia.

As exemplified by the situation in Cambodia, disease specific (vertical) health programmes are often favoured when the health system is fragile. The potential of such an approach to impede strengthening of primary healthcare services has been studied from a health systems perspective in terms of access and quality of care. In this bottom-up, qualitative study we investigate patient and community member experiences of health services when a strong tuberculosis (TB) programme is embedded into a relatively underutilized primary healthcare system. We conducted six gender-stratified community focus group discussions (n = 49) and seven mixed-gender focus group discussions with TB patients (n = 45) in three provinces located in urban, peri-urban and rural areas of Cambodia. Our analysis of health-seeking behaviour and experiences for TB and TB-like illness indicates that building a strong vertical TB control programme has had numerous benefits, including awareness of typical symptoms and need to seek care early; confidence in free TB services at public facilities; and willingness to complete treatment. However, there was a clear dichotomy in experiences and behaviour with respect to care-seeking for less severe illness at primary health services, which were generally avoided owing to access barriers and perceived poor quality. The tendency to delay seeking health care until the development of severe symptoms clearly indicative of TB is a major barrier to early diagnosis and treatment of TB. Our study indicates that an imbalance in the strength of vertical and primary health services could be a lose-lose situation as this impedes improvements in health system functioning and constrains progress of vertical disease control programmes.

Large funding inflows, limited local capacity and emerging disease control priorities: a situational assessment of tuberculosis control in Myanmar.

There are numerous challenges in planning and implementing effective disease control programmes in Myanmar, which is undergoing internal political and economic transformations whilst experiencing massive inflows of external funding. The objective of our study-involving key informant discussions, participant observations and linked literature reviews-was to analyse how tuberculosis (TB) control strategies in Myanmar are influenced by the broader political, economic, epidemiological and health systems context using the Systemic Rapid Assessment conceptual and analytical framework. Our findings indicate that the substantial influx of donor funding, in the order of one billion dollars over a 5-year period, may be too rapid for the country's infrastructure to effectively utilize. TB control strategies thus far have tended to favour medical or technological approaches rather than infrastructure development, and appear to be driven more by perceived urgency to 'do something' rather informed by evidence of cost-effectiveness and sustainable long-term impact. Progress has been made towards ambitious targets for scaling up treatment of drug-resistant TB, although there are concerns about ensuring quality of care. We also find substantial disparities in health and funding allocation between regions and ethnic groups, which are related to the political context and health system infrastructure. Our situational assessment of emerging TB control strategies in this transitioning health system indicates that large investments by international donors may be pushing Myanmar to scale up TB and drug-resistant TB services too quickly, without due consideration given to the health system (service delivery infrastructure, human resource capacity, quality of care, equity) and epidemiological (evidence of effectiveness of interventions, prevention of new cases) context.

Preventing emergence of drug resistant tuberculosis in Myanmar's transitioning health system.

Multidrug-resistant tuberculosis (MDR-TB) is a particular threat to the populations of resource-limited countries. Although inadequate treatment of TB has been identified as a major underlying cause of drug resistance, essential information to inform changes in health service delivery and policy is missing. We investigate factors that may be driving the emergence of MDR-TB in Myanmar, a country where investment and health system reforms are ongoing to address the unexplained, high occurrence of MDR-TB. We conducted a multi-centre, retrospective case-control study in 10 townships across Yangon. Cases were 202 GeneXpert-confirmed MDR-TB patients with a history of prior first-line treatment for TB. Controls were 404 previously untreated smear-microscopy confirmed TB patients who had no evidence of resistance to anti-TB drugs. Information on patient and health service factors was collected through face-to-face patient interviews and hospital record reviews. Multivariable logistic regression analysis indicated that the following TB patient groups are at higher risk of developing MDR-TB after initial TB treatment: those who have diabetes (aOR 2.10; 95% CI 1.17-3.76), those who missed taking drugs during the initial treatment more than once weekly (aOR 2.35; 95% CI 1.18-4.65) and those with a higher socioeconomic (aOR 1.99; 95% CI 1.09-3.63) or educational status (aOR 1.78; 95% CI1.01-3.13). Coinciding with a surge in funding to improve health in Myanmar, this study identifies practices of patients and healthcare organizations that can be addressed, and high-risk TB patient groups that can be prioritized for treatment support. Specifically, the study shows that TB patients who experience frequent, short interruptions in treatment and those with diabetes may require enhanced treatment support and monitoring by health services in order to prevent further generation of drug resistance.

Pandemic legislation in the European Union: Fit for purpose? The need for a systematic comparison of national laws.

Sound governance is central to effective pandemic management. Key international legal instruments governing pandemic management in the European Union (EU): the International Health Regulations (2005) and Decision 1082/13 require EU Member States to develop national plans and invite them to establish national legal frameworks to support compliance with this international legislation. Although Member States may design the legal framework as they choose, the strongest instrument of pandemic governance is national legislation. It is currently unclear what national pandemic governance exists in Member States as it has not been mapped, i.e. identified and collated. Legal analysis and empirical evaluation of implementation and impact have therefore not been possible. We propose comprehensive mapping to create the necessary comparative data for legal analysis assessing national legislation's compliance with international obligations and ethical principles. Empirical research could evaluate its effectiveness in promoting cross-border coherence and robust emergency response. We draw on the U.S. experience with "policy surveillance", the systematic scientific mapping of laws of public health importance. Until national pandemic governance is mapped and evaluated, we cannot know if it is lawful, ethical or effective.

Mapping infectious disease hospital surge threats to lessons learnt in Singapore: a systems analysis and development of a framework to inform how to DECIDE on planning and response strategies.

BACKGROUND: Hospital usage and service demand during an Infectious Disease (ID) outbreak can tax the health system in different ways. Herein we conceptualize hospital surge elements, and lessons learnt from such events, to help build appropriately matched responses to future ID surge threats. METHODS: We used the Interpretive Descriptive qualitative approach. Interviews (n = 35) were conducted with governance and public health specialists; hospital based staff; and General Practitioners. Key policy literature in tandem with the interview data were used to iteratively generate a Hospital ID Surge framework. We anchored our narrative account within this framework, which is used to structure our analysis. RESULTS: A spectrum of surge threats from combinations of capacity (for crowding) and capability (for treatment complexity) demands were identified. Starting with the Pyramid scenario, or an influx of high screening rates flooding Emergency Departments, alongside fewer and manageable admissions; the Reverse-Pyramid occurs when few cases are screened and admitted but those that are, are complex; during a 'Black' scenario, the system is overburdened by both crowding and complexity. The Singapore hospital system is highly adapted to crowding, functioning remarkably well at constant near-full capacity in Peacetime and resilient to Endemic surges. We catalogue 26 strategies from lessons learnt relating to staffing, space, supplies and systems, crystalizing institutional memory. The DECIDE model advocates linking these strategies to types of surge threats and offers a step-by-step guide for coordinating outbreak planning and response. CONCLUSIONS: Lack of a shared definition and decision making of surge threats had rendered the procedures somewhat duplicative. This burden was paradoxically exacerbated by a health system that highly prizes planning and forward thinking, but worked largely in silo until an ID crisis hit. Many such lessons can be put into play to further strengthen our current hospital governance and adapted to more diverse settings.

Tuberculosis active case finding in Cambodia: a pragmatic, cost-effectiveness comparison of three implementation models.

BACKGROUND: Globally, almost 40% of tuberculosis (TB) patients remain undiagnosed, and those that are diagnosed often experience prolonged delays before initiating correct treatment, leading to ongoing transmission. While there is a push for active case finding (ACF) to improve early detection and treatment of TB, there is extremely limited evidence about the relative cost-effectiveness of different ACF implementation models. Cambodia presents a unique opportunity for addressing this gap in evidence as ACF has been implemented using different models, but no comparisons have been conducted. The objective of our study is to contribute to knowledge and methodology on comparing cost-effectiveness of alternative ACF implementation models from the health service perspective, using programmatic data, in order to inform national policy and practice. METHODS: We retrospectively compared three distinct ACF implementation models - door to door symptom screening in urban slums, checking contacts of TB patients, and door to door symptom screening focusing on rural populations aged above 55 - in terms of the number of new bacteriologically-positive pulmonary TB cases diagnosed and the cost of implementation assuming activities are conducted by the national TB program of Cambodia. We calculated the cost per additional case detected using the alternative ACF models. RESULTS: Our analysis, which is the first of its kind for TB, revealed that the ACF model based on door to door screening in poor urban areas of Phnom Penh was the most cost-effective (249 USD per case detected, 737 cases diagnosed), followed by the model based on testing contacts of TB patients (308 USD per case detected, 807 cases diagnosed), and symptomatic screening of older rural populations (316 USD per case detected, 397 cases diagnosed). CONCLUSIONS: Our study provides new evidence on the relative effectiveness and economics of three implementation models for enhanced TB case finding, in line with calls for data from 'routine conditions' to be included in disease control program strategic planning. Such cost-effectiveness comparisons are essential to inform resource allocation decisions of national policy makers in resource constraint settings. We applied a novel, pragmatic methodological approach, which was designed to provide results that are directly relevant to policy makers, costing the interventions from Cambodia's national TB program's perspective and using case finding data from implementation activities, rather than experimental settings.

Comparing patient and healthcare worker experiences during a dengue outbreak in Singapore: understanding the patient journey and the introduction of a point-of-care test (POCT) toward better care delivery.

BACKGROUND: In the aftermath of an upsurge in the number of dengue cases in 2013 and 2014, the SD BIOLINE Dengue Duo rapid diagnostic Point-of-Care Test (POCT) kit was introduced in Tan Tock Seng Hospital, Singapore in June 2013. It is known that the success of POCT usage is contingent on its implementation within the health system. We evaluated health services delivery and the Dengue Duo rapid diagnostic test kit application in Singapore from healthcare workers' perspectives and patient experiences of dengue at surge times. METHODS: Focus group discussions were conducted with dengue patients, from before and after the POCT implementation period. In-depth interviews with semi-structured components with healthcare workers were carried out. A patient centred process mapping technique was used for evaluation, which mapped the patient's journey and was mirrored from the healthcare worker's perspective. RESULTS: Patients and healthcare workers confirmed a wide range of symptoms in adults, making it challenging to determine diagnosis. There were multiple routes to help seeking, and no 'typical patient journey', with patients either presenting directly to the hospital emergency department, or being referred there by a primary care provider. Patients groups diagnosed before and after POCT implementation expressed some differences between speed of diagnoses and attitudes of doctors, yet shared negative feelings about waiting times and a lack of communication and poor information delivery. However, the POCT did not in its current implementation do much to help waiting times. Healthcare workers expressed that public perceptions of dengue in recent years was a major factor in changing patient management, and that the POCT kit was helpful in improving the speed and accuracy of diagnoses. CONCLUSIONS: Health service delivery for dengue patients in Singapore was overall perceived to be of an acceptable clinical standard, which was enhanced by the introduction of the POCT. However, improvements can be focused on Adapting to outbreaks by reducing and rendering Waiting experiences more comfortable; Advancing education about symptom recognition, while also Recognising better communication strategies; and Expanding follow-up care options. This is presented as the Dengue AWARE model of care delivery.

Risk factors that may be driving the emergence of drug resistance in tuberculosis patients treated in Yangon, Myanmar.

BACKGROUND: The majority of new tuberculosis cases emerging every year occur in low and middle-income countries where public health systems are often characterised by weak infrastructure and inadequate resources. This study investigates healthcare seeking behaviour, knowledge and treatment of tuberculosis patients in Myanmar-which is facing an acute drug-resistant tuberculosis epidemic-and identifies factors that may increase the risk of emergence of drug-resistant tuberculosis. METHODS: We randomly selected adult smear-positive pulmonary tuberculosis patients diagnosed between September 2014 and March 2015 at ten public township health centres in Yangon, the largest city in Myanmar. Data on patients' healthcare seeking behaviour, treatment at the township health centres, co-morbidities and knowledge was collected through patient interviews and extraction from hospital records. A retrospective descriptive cross-sectional analysis was conducted. RESULTS: Of 404 TB patients selected to participate in the study, 11 had died since diagnosis, resulting in 393 patients being included in the final analysis. Results indicate that a high proportion of patients (16%; 95% CI = 13-20) did not have a treatment supporter assigned to improve adherence to medication, with men being more likely to have no treatment supporter assigned. Use of private healthcare providers was very common; 59% (54-64) and 30.3% (25.9-35.0) of patients reported first seeking care at private clinics and pharmacies respectively. We found that 8% (6-11) of tuberculosis patients had confirmed diabetes. Most patients had some knowledge about tuberculosis transmission and the consequences of missing treatment. However, 5% (3-8) stated that they miss taking tuberculosis medicines at least weekly, and patients with no knowledge of consequences of missing treatment were more likely to miss doses. CONCLUSIONS: This study analysed healthcare seeking behaviour and treatment related practices of tuberculosis patients being managed under operational conditions in a fragile health system. Findings indicate that ensuring that treatment adherence support is arranged for all patients, monitoring of response to treatment among the high proportion of tuberculosis patients with diabetes and engagement with private healthcare providers could be strategies addressed to reduce the risk of emergence of drug-resistant tuberculosis.

Guidelines, law, and governance: disconnects in the global control of airline-associated infectious diseases.

International air travel is increasingly affecting the epidemiology of infectious diseases. A particular public health, economic, and political concern is the role of air travel in bringing infectious passengers or vectors to previously non-endemic areas. Yet, little research has been done to investigate either the infection risks associated with air travel or the empirical evidence for the effectiveness of infection control measures on aircraft and at borders. We briefly review the interface between international and national legislation, policy, and guidelines in the context of existing infection risks and possible scenarios. We have found that public health guidance and legislation, which airlines are required to follow, are often contradictory and confusing. Infection control measures for air travel need to be underpinned by coherent and enforceable national and international legislation that is based on solid epidemiological evidence. We recommend further research investment into more effective on-board vector control, health screening, and risk communications strategies, and the development of enforceable and harmonised international legislation.

Justice Is the Missing Link in One Health: Results of a Mixed Methods Study in an Urban City State.

BACKGROUND: One Health (OH) is an interdisciplinary collaborative approach to human and animal health that aims to break down conventional research and policy 'silos'. OH has been used to develop strategies for zoonotic Emerging Infectious Diseases (EID). However, the ethical case for OH as an alternative to more traditional public health approaches is largely absent from the discourse. To study the ethics of OH, we examined perceptions of the human health and ecological priorities for the management of zoonotic EID in the Southeast Asia country of Singapore. METHODS: We conducted a mixed methods study using a modified Delphi technique with a panel of 32 opinion leaders and 11 semi-structured interviews with a sub-set of those experts in Singapore. Panellists rated concepts of OH and priorities for zoonotic EID preparedness planning using a series of scenarios developed through the study. Interview data were examined qualitatively using thematic analysis. FINDINGS: We found that panellists agreed that OH is a cross-disciplinary collaboration among the veterinary, medical, and ecological sciences, as well as relevant government agencies encompassing animal, human, and environmental health. Although human health was often framed as the most important priority in zoonotic EID planning, our qualitative analysis suggested that consideration of non-human animal health and welfare was also important for an effective and ethical response. The panellists also suggested that effective pandemic planning demands regional leadership and investment from wealthier countries to better enable international cooperation. CONCLUSION: We argue that EID planning under an OH approach would benefit greatly from an ethical ecological framework that accounts for justice in human, animal, and environmental health.