Molnupiravir versus favipiravir in at-risk outpatients with COVID-19: A randomized controlled trial in Thailand.

OBJECTIVES: Evaluate and compare the efficacy and safety of molnupiravir and favipiravir in outpatients with mild to moderate COVID-19 and at risk of severe COVID-19. METHODS: In an open-label, parallel-group, multicenter trial in Thailand, participants with moderate COVID-19 and at least one factor associated with severe COVID-19 were randomly assigned 1:1 to receive oral molnupiravir or oral favipiravir (standard of care). Phone calls for remote symptom assessment were made on Days 6, 15, and 29. Participants with worsening symptoms were instructed to return to the hospital. The primary endpoint was pulmonary involvement by Day 29, as evidenced by ≥2 of the following: dyspnea, oxygen saturation <92% or imaging. RESULTS: Nine hundred seventy-seven participants (487 molnupiravir, 490 favipiravir) were enrolled from 8 July 2022 to 19 January 2023. 98% had received ≥1 dose of COVID-19 vaccine and 83% ≥3 doses. By Day 29, pulmonary involvement occurred in 0% (0/483) in molnupiravir arm versus 1% (5/482) in favipiravir arm (-1.0%; Newcombe 95.2% CI: -2.4% to -0.0%; P = 0.021); all-cause death in 0% (0/483) and <1% (1/482); COVID-19 related hospitalization in <1% (1/483) and 1% (3/482); treatment-related adverse event in 1% (5/483) and 1% (4/486); and serious adverse event in 1% (4/483) and 1% (4/486). CONCLUSIONS: Favipiravir and molnupiravir had a similar efficacy and safety profile. Whether either of the two reduced the risk of complications during the omicron era in this population with a low risk of pulmonary involvement and a high vaccine coverage remains unclear. There were no differences in any of the safety endpoints. THAI CLINICAL TRIALS REGISTRY ID: TCTR20230111009.

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.

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.

Health equity and COVID-19: global perspectives.

The COVID-19 is disproportionally affecting the poor, minorities and a broad range of vulnerable populations, due to its inequitable spread in areas of dense population and limited mitigation capacity due to high prevalence of chronic conditions or poor access to high quality public health and medical care. Moreover, the collateral effects of the pandemic due to the global economic downturn, and social isolation and movement restriction measures, are unequally affecting those in the lowest power strata of societies. To address the challenges to health equity and describe some of the approaches taken by governments and local organizations, we have compiled 13 country case studies from various regions around the world: China, Brazil, Thailand, Sub Saharan Africa, Nicaragua, Armenia, India, Guatemala, United States of America (USA), Israel, Australia, Colombia, and Belgium. This compilation is by no-means representative or all inclusive, and we encourage researchers to continue advancing global knowledge on COVID-19 health equity related issues, through rigorous research and generation of a strong evidence base of new empirical studies in this field.

Cost-Effectiveness Analysis of Xpert MTB/RIF for Multi-Outcomes of Patients With Presumptive Pulmonary Tuberculosis in Thailand.

OBJECTIVES: The cost-effectiveness of screening adult patients for pulmonary tuberculosis is not clear. As such, this study aims to identify the cost-effectiveness between the Xpert MTB/RIF assay and the sputum acid-fast bacilli (AFB) smear. Multi-outcomes were correct diagnosis, time to achieve correct diagnosis, and gain in quality-adjusted life-years (QALYs). METHODS: A decision tree model was constructed to reveal a possible clinical pathway of tuberculosis diagnosis. The researchers used a clinical study to establish the probability of all clinical pathways for input into this model. The sample size was calculated following the correct diagnosis. Participants were randomly divided into 2 groups. A structural questionnaire and the Thai version of quality of life (EQ-5D-5L) were used for interviewing. RESULTS: The results showed that the time to achieve the correct diagnosis for the group using Xpert MTB/RIF was shorter than that for the group using the sputum AFB smear. Both the correct diagnosis and QALYs of the base case analysis presented the Xpert MTB/RIF method as dominant. A Monte Carlo model, which analyzed the Xpert MTB/RIF method, revealed that the average number of patients who were correctly diagnosed was 673, the QALYs were 945.85 years, and the total cost was $143 110.64. For the sputum AFB smear method, the average number who received a correct diagnosis was 592, the QALYs were 940.40 years, and the total cost was $196 666.84. Probabilistic and one-way sensitivity analysis confirmed that the Xpert MTB/RIF remained dominant. CONCLUSIONS: These results provide useful information for the National Strategic Plan to screen all adult patients for pulmonary tuberculosis.

Contact Mixing Patterns and Population Movement among Migrant Workers in an Urban Setting in Thailand.

Data relating to contact mixing patterns among humans are essential for the accurate modeling of infectious disease transmission dynamics. Here, we describe contact mixing patterns among migrant workers in urban settings in Thailand, based on a survey of 369 migrant workers of three nationalities. Respondents recorded their demographic data, including age, sex, nationality, workplace, income, and education. Each respondent chose a single day to record their contacts; this resulted in a total of more than 8300 contacts. The characteristics of contacts were recorded, including their age, sex, nationality, location of contact, and occurrence of physical contact. More than 75% of all contacts occurred among migrants aged 15 to 39 years. The contacts were highly clustered in this age group among migrant workers of all three nationalities. There were far fewer contacts between migrant workers with younger and older age groups. The pattern varied slightly among different nationalities, which was mostly dependent upon the types of jobs taken. Half of migrant workers always returned to their home country at most once a year and on a seasonal basis. The present study has helped us gain a better understanding of contact mixing patterns among migrant workers in urban settings. This information is useful both when simulating disease epidemics and for guiding optimal disease control strategies among this vulnerable section of the population.

Impact of sugar-sweetened beverage tax on dental caries: a simulation analysis.

BACKGROUND: The tiered sugar-sweetened beverage (SSB) tax was implemented in Thailand to encourage industries to reduce sugar content in beverages, and consequently reduce sugar consumption in the population. The aim of the study is to explore the expected impact of the new SSB tax policy in Thailand, a middle-income country in Asia, and other alternative policies on oral health outcomes as measured by the prevalence and severity of dental caries among the Thai population. METHODS: A qualitative system dynamics model that captures the complex interrelationships among SSB tax, sugar consumption and dental caries, was elicited through participatory stakeholder engagement. Based on the qualitative model, a quantitative system dynamics model was developed to simulate the SSB tax policy and other alternative scenarios in order to evaluate their impact on dental caries among Thai adults from 2010 to 2040. RESULTS: Under the base-case scenario, the dental caries prevalence among the Thai population 15 years and older, is projected to increase from 61.3% in 2010 to 74.9% by 2040. Implementation of SSB tax policy is expected to decrease the prevalence of dental caries by only 1% by 2040, whereas the aggressive policy is projected to decrease prevalence of dental caries by 21% by 2040. CONCLUSIONS: In countries where a majority of the sugar consumed is from non-tax sugary food and beverages, especially Asian countries where street food culture is ubiquitous and contributes disproportionately to sugar intake, SSB tax alone is unlikely to have meaningful impact on oral health unless it is accompanied with a comprehensive public health policy that aims to reduce total sugar intake from non-SSB sources.

Universal coverage but unmet need: National and regional estimates of attrition across the diabetes care continuum in Thailand.

BACKGROUND: Diabetes is a growing challenge in Thailand. Data to assess health system response to diabetes is scarce. We assessed what factors influence diabetes care cascade retention, under universal health coverage. METHODS: We conducted a cross-sectional analysis of the 2014 Thai National Health Examination Survey. Diabetes was defined as fasting plasma glucose ≥126mg/dL or on treatment. National and regional care cascades were constructed across screening, diagnosis, treatment, and control. Unmet need was defined as the total loss across cascade levels. Logistic regression was used to examine the demographic and healthcare factors associated with cascade attrition. FINDINGS: We included 15,663 individuals. Among Thai adults aged 20+ with diabetes, 67.0% (95% CI 60.9% to 73.1%) were screened, 34.0% (95% CI 30.6% to 37.2%) were diagnosed, 33.3% (95% CI 29.9% to 36.7%) were treated, and 26.0% (95% CI 22.9% to 29.1%) were controlled. Total unmet need was 74.0% (95% CI 70.9% to 77.1%), with regional variation ranging from 58.4% (95% CI 45.0% to 71.8%) in South to 78.0% (95% CI 73.0% to 83.0%) in Northeast. Multivariable models indicated older age (OR 1.76), males (OR 0.65), and a higher density of medical staff (OR 2.40) and health centers (OR 1.58) were significantly associated with being diagnosed among people with diabetes. Older age (OR 1.80) and higher geographical density of medical staff (OR 1.82) and health centers (OR 1.56) were significantly associated with being controlled. CONCLUSIONS: Substantial attrition in the diabetes care continuum was observed at diabetes screening and diagnosis, related to both individual and health system factors. Even with universal health insurance, Thailand still needs effective behavioral and structural interventions, especially in primary health care settings, to address unmet need in diabetes care for its population.

Impact of Buddhist Lent Dry Campaign on alcohol consumption behaviour: A community level study.

"Buddhist Lent Dry Campaign" is an alcohol-control programme that uses religious opportunities to promote behavioural changes among the Thai population. It is undertaken at the national and community levels. This study aimed to systematically evaluate the effectiveness of the community-level intervention under the campaign on alcohol consumption behaviour. A prospective cohort study was conducted. The sample comprised 447 drinkers from four intervention communities and 388 from four non-intervention communities. All were subjected to a series of sequential interviews. Our findings showed that the availability of the community intervention had a significant effect on alcohol abstinence not only during Buddhist Lent (OR = 2.74, 95% CI = 1.96, 3.85), but also 3 months after the end of Buddhist Lent (OR = 2.19, 95% CI = 1.42, 3.38). Furthermore, the intervention was very effective among drinkers who took an abstinence pledge (OR = 7.04, 95% CI = 4.49, 11.04). However, the effectiveness of the community intervention weakened after the intervention it ended. Additional interventions might be required to maintain the effects of the community intervention.

Effectiveness of Tuberculosis Screening Technology in the Initiation of Correct Diagnosis of Pulmonary Tuberculosis at a Tertiary Care Hospital in Thailand: Comparative Analysis of Xpert MTB/RIF Versus Sputum AFB Smear.

Pulmonary tuberculosis (PTB) is one of the top 10 causes of mortality worldwide in 2016. Early detection is very important, as it can help early treatment. This study compared 2 separate methods of diagnosing PTB among suspected patients, specifically examining correct diagnosis and the duration of receiving a correct diagnosis. It was carried out in a tertiary care public hospital in Bangkok, Thailand. Ninety patients were randomly assigned to 2 groups, one with the Xpert MTB/RIF ( Mycobacterium tuberculosis/rifampicin) and the other with sputum AFB (acid-fast bacilli) smear. The proportion of correct diagnosis was 90.9% and 83.7% for the Xpert MTB/RIF and the comparison group, respectively. The difference was not statistically significant ( P > .05). However, the time to correct diagnosis in the Xpert MTB/RIF group was significantly shorter than the comparison group (2.23 days). This could lead to early diagnosis and lower transmission rate of PTB cases. Results support the provision of Xpert MTB/RIF as the initial diagnostic test for PTB in Thailand.

Equality in financial access to healthcare in Cambodia from 2004 to 2014.

Since the end of its internal conflict in 1998, Cambodia has experienced tremendous developments in the social, economic and health sectors, with the government embarking on substantial reforms in health financing. Health equity funds that have improved access to public health services for poor people have gradually been extended to the entire country. Using the World Health Organization's methods for the analysis of healthcare expenditure and household survey data from the 2004, 2009 and 2014 Cambodian Socio-Economic Survey, we assessed trends in reported illness, utilization of healthcare services and associated financial burden on households. The impact of out-of-pocket expenditures for health on catastrophic health expenditures, poverty headcount and depth over the same 10-year period are presented, disaggregated by consumption quintile and place of residence (rural, urban and capital). At the aggregated national level, evolution of these indicators was very positive and correlates with a substantial increase in the capacity-to-pay of households, which reduced the average financial burden on households. However, over time inequalities grew between rural and urban areas. By 2014, the national incidence of catastrophic health expenditure was 4.9%, but four times more likely among rural households than their peers in the capital. For rural households with members seeking medical care, catastrophic health expenditure incidence was 12.3%. The impoverishment rate due to health spending among the lowest consumption quintile was 15.3%; the highest rate in this analysis. These findings suggest that economic and health sector developments have indeed benefited many Cambodian people. However, these gains mainly benefited urban residents; especially those in the capital city. We argue that more resources should be allocated to rural health services to address inequalities and healthcare-related financial hardship, which traps vulnerable people into poverty.

Assessment of population coverage of hypertension screening in Thailand based on the effective coverage framework.

BACKGROUND: Hypertension (HT) is a major risk factor, and accessible and effective HT screening services are necessary. The effective coverage framework is an assessment tool that can be used to assess health service performance by considering target population who need and receive quality service. The aim of this study is to measure effective coverage of hypertension screening services at the provincial level in Thailand. METHODS: Over 40 million individual health service records in 2013 were acquired. Data on blood pressure measurement, risk assessment, HT diagnosis and follow up were analyzed. The effectiveness of the services was assessed based on a set of quality criteria for pre-HT, suspected HT, and confirmed HT cases. Effective coverage of HT services for all non-HT Thai population aged 15 or over was estimated for each province and for all Thailand. RESULTS: Population coverage of HT screening is 54.6%, varying significantly across provinces. Among those screened, 28.9% were considered pre-HT, and another 6.0% were suspected HT cases. The average provincial effective coverage was at 49.9%. Around four-fifths (82.6%) of the pre-HT group received HT and Cardiovascular diseases (CVD) risk assessment. Among the suspected HT cases, less than half (38.0%) got a follow-up blood pressure measurement within 60 days from the screening date. Around 9.2% of the suspected cases were diagnosed as having HT, and only one-third of them (36.5%) received treatment within 6 months. Within this group, 21.8% obtained CVD risk assessment, and half of them had their blood pressure under control (50.8%) with less than 1 % (0.7%) of them managed to get the CVD risk reduced. CONCLUSIONS: Our findings suggest that hypertension screening coverage, post-screening service quality, and effective coverage of HT screening in Thailand were still low and they vary greatly across provinces. It is imperative that service coverage and its effectiveness are assessed, and both need improvement. Despite some limitations, measurement of effective coverage could be done with existing data, and it can serve as a useful tool for performance measurement of public health services.

Comparison of Cost-Effectiveness Between Actinomycin D Versus Methotrexate-Folinic Acid in the Treatment of Low-Risk Gestational Trophoblastic Neoplasia.

OBJECTIVE: To compare the cost-effectiveness between actinomycin D (Act-D) and methotrexate-folinic acid (MTX-FA) in the treatment of low-risk gestational trophoblastic neoplasia (GTN) in the Thai population. STUDY DESIGN: A comparative cost-effectiveness analysis was performed from a societal perspective. A decision tree model was developed comparing 2 alternative treatment options: initial 5-day Act-D and 8-day MTX-FA. Treatment would be switched to another regimen in case of resistance. The outcome of interest is number of days to remission. Clinical data was obtained from our previous study in which Act-D demonstrated 100% remission rates as compared to 73.6% for MTX-FA. Cost of treatment data, which includes chemotherapeutics, accessory medications, laboratory tests, and hospital fees, was obtained from a university hospital. Patient-related travel cost and opportunity cost due to absence from work were also included. All costs were calculated to 2015 base year. RESULT: Costs per treatment cycle were $308.01 and $227.20 US dollars (USD) for 5-day Act-D and 8-day MTX-FA, respectively. Expected time toward treatment completion for Act-D was 12.6 days shorter than for MTX-FA. Expected costs toward remission for initial treatment with Act-D and MTX-FA were $1,078.04 and $1,064.56 USD, respectively, i.e., an incremental cost effectiveness ratio (ICER) of $1.07 USD/day of earlier treatment completion. After sensitivity analysis, remission rate of lower than 72% would make initial treatment with MTX-FA more expensive than with Act-D. CONCLUSION: Treatment costs of low-risk GTN are almost equal between the 2 treatment options with different time to remission. Initial treatment with MTX-FA is slightly less expensive, but there is longer time to remission. The ICER of initial treatment with Act-D over MTX-FA is $1.07 USD/day of earlier treatment completion.

Cost Effectiveness Analysis of Different Management Strategies between Best Supportive Care and Second-line Chemotherapy for Platinum-resistant or Refractory Ovarian Cancer.

BACKGROUND: There is no standard treatment for patients with platinum-resistant or refractory epithelial ovarian cancer. Single agent chemotherapies have evidence of more efficacy and less toxicity than combination therapy. Most are very expensive, with appreciable toxicity and minimal survival. Since it is difficult to make comparison between outcomes, economic analysis of single-agent chemotherapy regimens and best supportive care may help to make decisions about an appropriate management for the affected patients. OBJECTIVE: To evaluate the cost effectiveness of second-line chemotherapy compared with best supportive care for patients with platinum-resistant or refractory epithelial ovarian cancer. MATERIALS AND METHODS: A Markov model was used to estimate the effectiveness and total costs associated with treatments. The hypothetical patient population comprised women aged 55 with platinum-resistant or refractory epithelial ovarian cancer. Four types of alternative treatment options were evaluated: 1) gemcitabine followed by BSC; 2) pegylated liposomal doxorubicin (PLD) followed by BSC; 3) gemcitabine followed by topotecan; and 4) PLD followed by topotecan. Baseline comparator of alternative treatments was BSC. Time horizon of the analysis was 2 years. Health care provider perspective and 3% discount rate were used to determine the costs of medical treatment in this study. Quality-adjusted life-years (QALY) were used to measure the treatment effectiveness. Treatment effectiveness data were derived from the literature. Costs were calculated from unit cost treatment of epithelial ovarian cancer patients at various stages of disease in King Chulalongkorn Memorial Hospital (KCMH) in the year 2011. Parameter uncertainty was tested in probabilistic sensitivity analysis by using Monte Carlo simulation. One-way sensitivity analysis was used to explore each variable's impact on the uncertainty of the results. RESULTS: Approximated life expectancy of best supportive care was 0.182 years and its total cost was 26,862 Baht. All four alternative treatments increased life expectancy. Life expectancy of gemcitabine followed by BSC, PLD followed by BSC, gemcitabine followed by topotecan and PLD followed by topotecan was 0.510, 0.513, 0.566, and 0.570 years, respectively. The total cost of gemcitabine followed by BSC, PLD followed by BSC, gemcitabine followed by topotecan and PLD followed by topotecan was 113,000, 124,302, 139,788 and 151,135 Baht, respectively. PLD followed by topotecan had the highest expected quality-adjusted life-years but was the most expensive of all the above strategies. The incremental cost-effectiveness ratios (ICER) of gemcitabine followed by BSC, PLD followed by BSC, gemcitabine followed by topotecan and PLD followed by topotecan was 344,643, 385,322, 385,856, and 420,299 Baht, respectively. CONCLUSIONS: All of the second-line chemotherapy strategies showed certain benefits due to an increased life- year gained compared with best supportive care. Moreover, gemcitabine as second-line chemotherapy followed by best supportive care in progressive disease case was likely to be more effective strategy with less cost from health care provider perspective. Gemcitabine was the most cost-effective treatment among all four alternative treatments. ICER is only an economic factor. Treatment decisions should be based on the patient benefit.

Equity in health personnel financing after Universal Coverage: evidence from Thai Ministry of Public Health's hospitals from 2008-2012.

BACKGROUND: Shortage and maldistribution of the health workforce is a major problem in the Thai health system. The expansion of healthcare access to achieve universal health coverage placed additional demand on the health system especially on the health workers in the public sector who are the major providers of health services. At the same time, the reform in hospital payment methods resulted in a lower share of funding from the government budgetary system and higher share of revenue from health insurance. This allowed public hospitals more flexibility in hiring additional staff. Financial measures and incentives such as special allowances for non-private practice and additional payments for remote staff have been implemented to attract and retain them. To understand the distributional effect of such change in health workforce financing, this study evaluates the equity in health workforce financing for 838 hospitals under the Ministry of Public Health across all 75 provinces from 2008-2012. METHODS: Data were collected from routine reports of public hospital financing from the Ministry of Public Health with specific identification on health workforce spending. The components and sources of health workforce financing were descriptively analysed based on the geographic location of the hospitals, their size and the core hospital functions. Inequalities in health workforce financing across provinces were assessed. We calculated the Gini coefficient and concentration index to explore horizontal and vertical inequity in the public sector health workforce financing in Thailand. Separate analyses were carried out for funding from government budget and funding from hospital revenue to understand the difference between the two financial sources. RESULTS: Health workforce financing accounted for about half of all hospital non-capital expenses in 2012, about a 30 % increase from the level of spending in 2008. Almost one third of the workforce financing came from hospital revenue, an increase from only one fourth 5 years earlier. The study reveals a big difference in health workforce expenditure per capita across provinces. Health workforce spending from government budget was less equal than that from hospital revenues as shown by the higher Gini coefficient. The concentration indices show that the financing of hospital workforce was higher per capita in lower resource provinces. CONCLUSION: Our analysis of equalities in health workforce spending shows an improving trend in equity across provinces from 2008-2012. Expansion of healthcare and health insurance coverage and financing reform towards a demand-side financing helped improve the distribution of funding for health workforce across the provinces. The findings from this study can be useful for other countries with ongoing reform towards universal health coverage.

Pandemic influenza and health system resource gaps in Bali: an analysis through a resource transmission dynamics model.

The failure to contain pandemic influenza A(H1N1) 2009 in Mexico has shifted global attention from containment to mitigation. Limited surveillance and reporting have, however, prevented detailed assessment of mitigation during the pandemic, particularly in low- and middle-income countries. To assess pandemic influenza case management capabilities in a resource-limited setting, the authors used a health system questionnaire and density-dependent, deterministic transmission model for Bali, Indonesia, determining resource gaps. The majority of health resources were focused in and around the provincial capital, Denpasar; however, gaps are found in every district for nursing staff, surgical masks, and N95 masks. A relatively low pathogenicity pandemic influenza virus would see an overall surplus for physicians, antivirals, and antimicrobials; however, a more pathogenic virus would lead to gaps in every resource except antimicrobials. Resources could be allocated more evenly across Bali. These, however, are in short supply universally and therefore redistribution would not fill resource gaps.

Progress toward universal health coverage in ASEAN.

BACKGROUND: The Association of Southeast Asian Nations (ASEAN) is characterized by much diversity in terms of geography, society, economic development, and health outcomes. The health systems as well as healthcare structure and provisions vary considerably. Consequently, the progress toward Universal Health Coverage (UHC) in these countries also varies. This paper aims to describe the progress toward UHC in the ASEAN countries and discuss how regional integration could influence UHC. DESIGN: Data reported in this paper were obtained from published literature, reports, and gray literature available in the ASEAN countries. We used both online and manual search methods to gather the information and 'snowball' further data. RESULTS: We found that, in general, ASEAN countries have made good progress toward UHC, partly due to relatively sustained political commitments to endorse UHC in these countries. However, all the countries in ASEAN are facing several common barriers to achieving UHC, namely 1) financial constraints, including low levels of overall and government spending on health; 2) supply side constraints, including inadequate numbers and densities of health workers; and 3) the ongoing epidemiological transition at different stages characterized by increasing burdens of non-communicable diseases, persisting infectious diseases, and reemergence of potentially pandemic infectious diseases. The ASEAN Economic Community's (AEC) goal of regional economic integration and a single market by 2015 presents both opportunities and challenges for UHC. Healthcare services have become more available but health and healthcare inequities will likely worsen as better-off citizens of member states might receive more benefits from the liberalization of trade policy in health, either via regional outmigration of health workers or intra-country health worker movement toward private hospitals, which tend to be located in urban areas. For ASEAN countries, UHC should be explicitly considered to mitigate deleterious effects of economic integration. Political commitments to safeguard health budgets and increase health spending will be necessary given liberalization's risks to health equity as well as migration and population aging which will increase demand on health systems. There is potential to organize select health services regionally to improve further efficiency. CONCLUSIONS: We believe that ASEAN has significant potential to become a force for better health in the region. We hope that all ASEAN citizens can enjoy higher health and safety standards, comprehensive social protection, and improved health status. We believe economic and other integration efforts can further these aspirations.

An analysis of health system resources in relation to pandemic response capacity in the Greater Mekong Subregion.

BACKGROUND: There is increasing perception that countries cannot work in isolation to militate against the threat of pandemic influenza. In the Greater Mekong Subregion (GMS) of Asia, high socio-economic diversity and fertile conditions for the emergence and spread of infectious diseases underscore the importance of transnational cooperation. Investigation of healthcare resource distribution and inequalities can help determine the need for, and inform decisions regarding, resource sharing and mobilisation. METHODS: We collected data on healthcare resources deemed important for responding to pandemic influenza through surveys of hospitals and district health offices across four countries of the GMS (Cambodia, Lao PDR, Thailand, Vietnam). Focusing on four key resource types (oseltamivir, hospital beds, ventilators, and health workers), we mapped and analysed resource distributions at province level to identify relative shortages, mismatches, and clustering of resources. We analysed inequalities in resource distribution using the Gini coefficient and Theil index. RESULTS: Three quarters of the Cambodian population and two thirds of the Laotian population live in relatively underserved provinces (those with resource densities in the lowest quintile across the region) in relation to health workers, ventilators, and hospital beds. More than a quarter of the Thai population is relatively underserved for health workers and oseltamivir. Approximately one fifth of the Vietnamese population is underserved for beds and ventilators. All Cambodian provinces are underserved for at least one resource. In Lao PDR, 11 percent of the population is underserved by all four resource items. Of the four resources, ventilators and oseltamivir were most unequally distributed. Cambodia generally showed higher levels of inequalities in resource distribution compared to other countries. Decomposition of the Theil index suggests that inequalities result principally from differences within, rather than between, countries. CONCLUSIONS: There is considerable heterogeneity in healthcare resource distribution within and across countries of the GMS. Most inequalities result from within countries. Given the inequalities, mismatches, and clustering of resources observed here, resource sharing and mobilization in a pandemic scenario could be crucial for more effective and equitable use of the resources that are available in the GMS.