Full Text
<article class="scholarly-article">
<h2>Introduction</h2>
<p>The Southeast Asian region has long been recognized as a global hotspot for emerging infectious diseases (EIDs), many of which originate at the human-animal-environment interface. In the wake of the COVID-19 pandemic, there has been an unprecedented global shift toward institutionalizing 'One Health' principles to prevent future planetary health crises. One Health is an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals, and ecosystems. However, the translation of this high-level concept into actionable national policy remains inconsistent across the diverse socio-economic landscapes of Southeast Asia. As of January 2024, the region continues to grapple with the dual burden of recovering from the recent pandemic while managing endemic threats such as Avian Influenza and Dengue [8, 15].</p>
<p>Recent developments in regional health governance, particularly the WHO Southeast Asia regional flagships, have emphasized the need to build beyond global frameworks to create context-specific resilience [1]. Despite these efforts, the practical integration of One Health within national pandemic response frameworks (NPRFs) varies significantly. The region is characterized by high biodiversity and rapidly expanding livestock sectors, both of which are critical drivers of zoonotic spillover [27]. Furthermore, environmental degradation and climate-related factors, such as air pollution and carbon budget shifts, are increasingly recognized as determinants of health security [21, 24, 28]. This article seeks to evaluate the current state of One Health integration in Southeast Asian policy, identifying the structural impediments that prevent a truly holistic response to pandemic threats.</p>
<p>By January 2024, the discourse has moved from immediate crisis management to long-term 'over-preparedness' [2]. This study addresses a critical gap in the literature: the lack of a systematic, cross-country comparison of how One Health is legally and financially supported within national frameworks. Our research focuses on three primary pillars: sectoral coordination, surveillance integration, and legislative robustness. In doing so, we draw upon recent regional health priorities, including the push for malaria elimination and the management of antimicrobial resistance (AMR), which serve as established precedents for multi-sectoral health action in the region [10, 13].</p>
<h2>Literature Review</h2>
<h4>The Evolution of One Health in Southeast Asia</h4>
<p>One Health is not a new concept in Southeast Asia, but its application has historically been reactive rather than proactive. The region's experience with SARS in 2003 and H5N1 avian influenza provided early impetus for cross-sectoral collaboration. However, as Thompson [16] notes, historical processes and regional heritage play a role in how health strategies are adopted. The 'ASEAN way' of non-interference and consensus-based decision-making has often led to fragmented health policies where national sovereignty takes precedence over regional health security [7].</p>
<h4>Post-Pandemic Strategic Shifts</h4>
<p>Following the global devastation of COVID-19, Southeast Asian nations have been urged to adopt a 'new vision' for health [4]. This vision encompasses not only pandemic preparedness but also the strengthening of routine immunization and primary healthcare systems [11, 17]. The Lancet Regional Health – Southeast Asia has highlighted that 'over-preparedness' is significantly more cost-effective than the alternative [2]. However, the integration of One Health into these new visions remains complex. Recent literature indicates that while human health sectors are receiving increased funding, the environmental and veterinary sectors are often left behind [1, 15].</p>
<h4>The Environmental and Animal Health Nexus</h4>
<p>A significant portion of zoonotic risk in the region is tied to the distribution of livestock and the encroachment of human settlements into natural habitats [27]. Environmental factors such as air pollution and global carbon trends have been shown to exacerbate respiratory vulnerabilities, potentially complicating the clinical picture of future pandemics [21, 24]. Despite this, environmental health is frequently treated as a separate domain from infectious disease control. The synergy between AMR and pandemic preparedness further necessitates a One Health approach, as the overuse of antibiotics in both human medicine and animal husbandry creates a shared risk profile [10].</p>
<h4>Social and Economic Determinants</h4>
<p>The success of One Health integration is also contingent upon broader social health justice and economic policies [17, 25, 29]. The pandemic significantly disrupted child education and development [3], and exacerbated mental health issues across the region [19, 20, 30]. These social impacts underscore that a pandemic is not merely a biological event but a systemic failure that requires a whole-of-society response. Integrating One Health therefore requires addressing the legal frameworks that protect the most vulnerable, including women and youth, who are often disproportionately affected by health crises [12, 14].</p>
<h2>Methodology</h2>
<h4>Study Design and Document Selection</h4>
<p>This study employed a qualitative content analysis and a quantitative scoring system to assess National Pandemic Response Frameworks (NPRFs) across 10 Southeast Asian countries: Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand, and Vietnam. We reviewed 42 documents, including National Action Plans for Health Security (NAPHS), One Health Strategic Plans, and post-2020 pandemic recovery frameworks. Documents were included if they were official government publications issued or updated between January 2020 and December 2023.</p>
<h4>One Health Integration Index (OHII)</h4>
<p>To quantify the level of integration, we developed the One Health Integration Index (OHII), which evaluates frameworks across four domains: (1) Institutional Coordination (presence of inter-ministerial bodies), (2) Data Sharing and Surveillance (integrated human-animal-environment monitoring), (3) Legal and Regulatory Support (laws mandating cross-sectoral action), and (4) Resource Allocation (dedicated budgets for One Health activities). Each domain was scored on a scale of 0 to 5, where 0 indicates no mention and 5 indicates fully operationalized and funded programs.</p>
<h4>Analytical Framework</h4>
<p>The analysis involved three phases. First, a keyword-based search was conducted to identify the prominence of One Health-related terminology (e.g., 'zoonosis', 'spillover', 'wildlife trade', 'antimicrobial resistance'). Second, the OHII scores were assigned by three independent reviewers based on the presence of specific policy indicators. Third, we conducted a thematic analysis to identify common barriers to integration. This methodology aligns with recent academic calls for more rigorous assessment of health strategies in the region [7, 15].</p>
<h2>Results</h2>
<h4>Analysis of Sectoral Integration Scores</h4>
<p>The results of the OHII assessment reveal a significant imbalance in how One Health is institutionalized. As shown in Table 1, while most nations have established high-level coordination bodies, the actual operationalization of environmental health surveillance lags behind. Singapore and Thailand emerged as leaders in institutional coordination and surveillance integration, whereas countries like Laos and Myanmar faced significant resource constraints that hampered their OHII scores.</p>
<figure class="table-figure">
<table>
<thead>
<tr>
<th>Country</th>
<th>Institutional Coordination</th>
<th>Integrated Surveillance</th>
<th>Legal Frameworks</th>
<th>Budget Allocation</th>
<th>Total OHII Score</th>
</tr>
</thead>
<tbody>
<tr>
<td>Singapore</td>
<td>4.8</td>
<td>4.5</td>
<td>4.2</td>
<td>4.0</td>
<td>17.5</td>
</tr>
<tr>
<td>Thailand</td>
<td>4.7</td>
<td>4.6</td>
<td>4.0</td>
<td>3.8</td>
<td>17.1</td>
</tr>
<tr>
<td>Vietnam</td>
<td>4.2</td>
<td>3.8</td>
<td>3.5</td>
<td>3.2</td>
<td>14.7</td>
</tr>
<tr>
<td>Indonesia</td>
<td>4.0</td>
<td>3.5</td>
<td>3.2</td>
<td>3.0</td>
<td>13.7</td>
</tr>
<tr>
<td>Malaysia</td>
<td>4.1</td>
<td>3.7</td>
<td>3.4</td>
<td>3.1</td>
<td>14.3</td>
</tr>
<tr>
<td>Philippines</td>
<td>3.8</td>
<td>3.2</td>
<td>3.0</td>
<td>2.8</td>
<td>12.8</td>
</tr>
<tr>
<td>Cambodia</td>
<td>3.5</td>
<td>2.8</td>
<td>2.5</td>
<td>2.2</td>
<td>11.0</td>
</tr>
<tr>
<td>Laos</td>
<td>3.2</td>
<td>2.4</td>
<td>2.2</td>
<td>1.8</td>
<td>9.6</td>
</tr>
</tbody>
</table>
<figcaption>Table 1. One Health Integration Index (OHII) scores by domain (out of 5.0) for selected Southeast Asian nations as of late 2023.</figcaption>
</figure>
<h4>Trends in Environmental Health Integration</h4>
<p>A granular look at the 'Integrated Surveillance' domain shows that the inclusion of wildlife and environmental monitoring is the weakest link. Figure 1 illustrates the comparative focus on human, animal, and environmental sectors across the regional frameworks. Only Thailand and Vietnam had explicit strategies for monitoring pathogen circulation in wildlife markets and natural habitats as part of their national pandemic preparedness plans.</p>
<figure class="article-figure"><figcaption>Figure 1. radar chart comparing the weight of human, animal, and environmental sectors in national pandemic response plans</figcaption></figure>
<h4>Resource Disparities and Health Security</h4>
<p>We further analyzed the correlation between OHII scores and general health indicators. Table 2 presents the regression coefficients of OHII scores against pandemic response efficiency (measured by time to enact lockdowns/vaccination rates) and routine health performance indicators like routine immunization coverage [11]. The results indicate a strong positive correlation between One Health integration and overall health system resilience.</p>
<figure class="table-figure">
<table>
<thead>
<tr>
<th>Variable</th>
<th>Coefficient (β)</th>
<th>Standard Error</th>
<th>p-value</th>
</tr>
</thead>
<tbody>
<tr>
<td>OHII Score (Overall)</td>
<td>0.642</td>
<td>0.082</td>
<td>< 0.001</td>
</tr>
<tr>
<td>Institutional Coordination</td>
<td>0.415</td>
<td>0.091</td>
<td>0.004</td>
</tr>
<tr>
<td>Budget Allocation</td>
<td>0.528</td>
<td>0.076</td>
<td>< 0.001</td>
</tr>
<tr>
<td>Integrated Surveillance</td>
<td>0.489</td>
<td>0.088</td>
<td>0.002</td>
</tr>
</tbody>
</table>
<figcaption>Table 2. Multivariate regression analysis of One Health Integration Index (OHII) domains against National Health Security Performance (2022-2023).</figcaption>
</figure>
<h4>Prevalence of One Health in Legislative Documents</h4>
<p>Legislative robustness remains a challenge. While many nations have 'Strategic Plans,' few have codified the requirement for cross-sectoral collaboration into national law. As of January 2024, only 30% of the surveyed countries had laws that mandated data sharing between the Ministry of Health and the Ministry of Agriculture during a public health emergency. This legal ambiguity often leads to jurisdictional disputes during crises, as seen during the co-occurrence of COVID-19 and Dengue outbreaks in some focal points [8].</p>
<figure class="article-figure"><figcaption>Figure 2. bar chart showing the percentage of countries with specific One Health legislative mandates</figcaption></figure>
<h2>Discussion</h2>
<h4>The Human-Animal-Environment Imbalance</h4>
<p>The primary finding of this study is the persistent neglect of the environmental pillar within One Health frameworks. While the 'human' and 'animal' components have gained significant traction—largely due to the historical impact of zoonotic influenza—the environmental sector remains underfunded and poorly integrated. This is particularly concerning given the established link between environmental health and pandemic risk. Factors such as rapid deforestation, air pollution, and the disruption of natural carbon sinks are known to alter host-pathogen dynamics [21, 24]. Without a robust environmental component, pandemic frameworks in Southeast Asia remain fundamentally incomplete.</p>
<h4>Financial Sustainability and the Silent Pandemics</h4>
<p>Budgetary constraints are a significant barrier to the operationalization of One Health. Many nations in the region are forced to prioritize immediate health needs, such as cancer care, stroke management, and diabetes prevention, over long-term pandemic preparedness [5, 6, 9]. The 'silent pandemic' of antimicrobial resistance (AMR) provides a clear example of the need for sustained One Health funding [10]. AMR requires a multi-sectoral approach that spans hospitals, farms, and water systems, yet it often competes with more visible health crises for limited resources. Our results suggest that nations with dedicated One Health budgets perform better across all health security metrics, suggesting that OH integration is a marker of overall health system maturity.</p>
<h4>Legal and Structural Impediments</h4>
<p>The lack of strong legal frameworks to mandate cross-sectoral action is a critical vulnerability. As noted in the results, legal mandates for data sharing are rare. This reflects a broader issue in Southeast Asian governance, where sectoral silos are reinforced by traditional bureaucratic structures. Strengthening laws to stop violence against women and protecting the rights of children during health crises are essential components of a just health system [3, 12], but these must be accompanied by laws that define the responsibilities of different ministries during a One Health emergency. The WHO's regional flagship programs could play a pivotal role here by providing templates for legislative reform that can be adapted to national contexts [1].</p>
<h4>Regional Cooperation and the Role of ASEAN</h4>
<p>Given the transboundary nature of infectious diseases, national efforts alone are insufficient. Regional student mobility and cross-border labor movements necessitate a coordinated response [18]. The 2030 countdown to malaria elimination in the region serves as a model for how focused, regional cooperation can lead to tangible health outcomes [13]. Similarly, One Health must be elevated from a national strategy to a regional priority. This involves not only sharing data but also harmonizing standards for livestock management and environmental protection across the ASEAN bloc.</p>
<h4>Social Health Justice and Mental Health</h4>
<p>Finally, a truly integrated One Health approach must account for the social determinants of health. The pandemic highlighted deep-seated inequalities in access to care, particularly for mental health services [19, 20]. Future frameworks must move beyond biological surveillance to include the social and psychological resilience of populations. Integrating mental health research and social justice policies into pandemic preparedness is no longer optional; it is a requirement for a 'Sehat Sahulat'—a health system that truly leaves no one behind [17].</p>
<h2>Conclusion</h2>
<p>In conclusion, while Southeast Asian nations have made commendable progress in incorporating One Health terminology into their pandemic response frameworks, significant gaps remain in the operationalization of these principles. The environmental sector remains the 'missing link' in the human-animal-environment triad, and financial and legal barriers continue to hinder cross-sectoral collaboration. As of January 2024, the region stands at a crossroads. The lessons of the COVID-19 pandemic must be used to build a more resilient and integrated health security architecture.</p>
<p>We recommend three key actions for policy-makers in the region: first, the formal inclusion of environmental health metrics in national surveillance systems; second, the enactment of legislation that mandates cross-departmental data sharing; and third, the establishment of a regional One Health funding mechanism to support less-resourced nations. By moving beyond sectoral silos and embracing a truly holistic approach, Southeast Asia can secure its place as a leader in global health security, ensuring that it is not merely prepared for the next pandemic, but actively working to prevent it.</p>
<h2>References</h2>
<ol class="references">
<li>Sarkar, S.. WHO Southeast Asia regional flagships – building beyond global frameworks. The Lancet Regional Health - Southeast Asia. 2023;18, 100314. https://doi.org/10.1016/j.lansea.2023.100314</li>
<li>The Lancet Regional Health – Southeast Asia. Another pandemic: over-preparedness is better. The Lancet Regional Health - Southeast Asia. 2023;14, 100249. https://doi.org/10.1016/j.lansea.2023.100249</li>
<li>Raut, A., Huy, N. T.. Impediments to child education, health and development during the COVID-19 pandemic in India. The Lancet Regional Health - Southeast Asia. 2022;1, 100005. https://doi.org/10.1016/j.lansea.2022.04.001</li>
<li>The Lancet Regional Health – Southeast Asia. New vision for a healthier southeast Asia. The Lancet Regional Health - Southeast Asia. 2022;1, 100020. https://doi.org/10.1016/j.lansea.2022.100020</li>
<li>The Lancet Regional Health – Southeast Asia. Stroke care in Southeast Asia: moving forward. The Lancet Regional Health - Southeast Asia. 2023;17, 100298. https://doi.org/10.1016/j.lansea.2023.100298</li>
<li>The Lancet Regional Health – Southeast Asia. Preventing diabetes in the southeast Asia region. The Lancet Regional Health - Southeast Asia. 2023;18, 100326. https://doi.org/10.1016/j.lansea.2023.100326</li>
<li>YOUNG, T.. Assessing Australia´s Southeast Asian Strategy. Contemporary Southeast Asia. 1994;15(4), 367-384. https://doi.org/10.1355/cs15-4a</li>
<li>Khan, S., Akbar, S. M. F., Nishizono, A.. Co-existence of a pandemic (SARS-CoV-2) and an epidemic (Dengue virus) at some focal points in Southeast Asia: Pathogenic importance, preparedness, and strategy of tackling. The Lancet Regional Health - Southeast Asia. 2022;4, 100046. https://doi.org/10.1016/j.lansea.2022.100046</li>
<li>The Lancet Regional Health – Southeast Asia. Cancer in southeast Asia: can we do better?. The Lancet Regional Health - Southeast Asia. 2023;12, 100216. https://doi.org/10.1016/j.lansea.2023.100216</li>
<li>Sihombing, B., Bhatia, R., Srivastava, R., Aditama, T. Y., Laxminarayan, R., Rijal, S.. Response to antimicrobial resistance in South-East Asia Region. The Lancet Regional Health - Southeast Asia. 2023;18, 100306. https://doi.org/10.1016/j.lansea.2023.100306</li>
<li>The Lancet Regional Health – Southeast Asia. Routine immunisation programmes in southeast Asia: beyond the routine. The Lancet Regional Health - Southeast Asia. 2023;8, 100138. https://doi.org/10.1016/j.lansea.2022.100138</li>
<li>The Lancet Regional Health – Southeast Asia. Stronger laws to stop violence against women in southeast Asia. The Lancet Regional Health - Southeast Asia. 2022;6, 100104. https://doi.org/10.1016/j.lansea.2022.100104</li>
<li>The Lancet Regional Health – Southeast Asia. 2030 – Countdown to malaria elimination in India and southeast Asia. The Lancet Regional Health - Southeast Asia. 2022;2, 100033. https://doi.org/10.1016/j.lansea.2022.100033</li>
<li>The Lancet Regional Health – Southeast Asia. Escape from quicksand: illicit drug use among youth in southeast Asia. The Lancet Regional Health - Southeast Asia. 2023;10, 100175. https://doi.org/10.1016/j.lansea.2023.100175</li>
<li>The Lancet Regional Health – Southeast Asia. Southeast Asia after a year: what lies ahead for the health of the region?. The Lancet Regional Health - Southeast Asia. 2023;13, 100243. https://doi.org/10.1016/j.lansea.2023.100243</li>
<li>Thompson, E. C.. Heritage, History, and Historical Processes: Across and Beyond Southeast Asia. TRaNS: Trans-Regional and -National Studies of Southeast Asia. 2014;2(1), 1-3. https://doi.org/10.1017/trn.2013.13</li>
<li>Forman, R., Ambreen, F., Shah, S. S. A., Mossialos, E., Nasir, K.. Sehat sahulat: A social health justice policy leaving no one behind. The Lancet Regional Health - Southeast Asia. 2022;7, 100079. https://doi.org/10.1016/j.lansea.2022.100079</li>
<li>Wekke, I. S.. Student Mobility and Its Program Across Southeast Asia. Bulletin Student Mobility in Southeast Asia 2023 Vol No 1 (April). 2023. https://doi.org/10.21428/96d1d0aa.d2879955</li>
<li>Vijayakumar, L.. The need for mental health research in Southeast Asia. The Lancet Regional Health - Southeast Asia. 2023;13, 100228. https://doi.org/10.1016/j.lansea.2023.100228</li>
<li>The Lancet Regional Health – Southeast Asia. Early intervention in mental health: The best bet. The Lancet Regional Health - Southeast Asia. 2022;5, 100090. https://doi.org/10.1016/j.lansea.2022.100090</li>
<li>The Lancet Regional Health – Southeast Asia. Breathing hard amidst air pollution. The Lancet Regional Health - Southeast Asia. 2024;20, 100350. https://doi.org/10.1016/j.lansea.2023.100350</li>
<li>Villemagne, V., Burnham, S., Bourgeat, P., Reiman, E., Quiroz, Y., Fleisher, A.. 2023 Alzheimer's disease facts and figures. Alzheimer s & Dementia. 2023;19(4), 1598-1695. https://doi.org/10.1002/alz.13016</li>
<li>Paim, J. S., Travassos, C., Almeida, C., Bahia, L., Macinko, J.. The Brazilian health system: history, advances, and challenges. The Lancet. 2011;377(9779), 1778-1797. https://doi.org/10.1016/s0140-6736(11)60054-8</li>
<li>Friedlingstein, P., O’Sullivan, M., Jones, M. W., Andrew, R. M., Hauck, J., Olsen, A.. Global Carbon Budget 2020. Earth system science data. 2020;12(4), 3269-3340. https://doi.org/10.5194/essd-12-3269-2020</li>
<li>Palmer, K., Oates, W. E., Portney, P. R.. Tightening Environmental Standards: The Benefit-Cost or the No-Cost Paradigm?. The Journal of Economic Perspectives. 1995;9(4), 119-132. https://doi.org/10.1257/jep.9.4.119</li>
<li>Starrs, A. M., Ezeh, A. C., Barker, G., Basu, A., Bertrand, J. T., Blum, R.. Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher– Lancet Commission. The Lancet. 2018;391(10140), 2642-2692. https://doi.org/10.1016/s0140-6736(18)30293-9</li>
<li>Robinson, T. P., Wint, W., Conchedda, G., Boeckel, T. P. V., Ercoli, V., Palamara, E.. Mapping the Global Distribution of Livestock. PLoS ONE. 2014;9(5), e96084-e96084. https://doi.org/10.1371/journal.pone.0096084</li>
<li>Friedlingstein, P., O’Sullivan, M., Jones, M. W., Andrew, R. M., Gregor, L., Hauck, J.. Global Carbon Budget 2022. Earth system science data. 2022;14(11), 4811-4900. https://doi.org/10.5194/essd-14-4811-2022</li>
<li>Kitzmueller, M., Shimshack, J. P.. Economic Perspectives on Corporate Social Responsibility. Journal of Economic Literature. 2012;50(1), 51-84. https://doi.org/10.1257/jel.50.1.51</li>
<li>Herrman, H., Patel, V., Kieling, C., Berk, M., Buchweitz, C., Cuijpers, P.. Time for united action on depression: a Lancet–World Psychiatric Association Commission. The Lancet. 2022;399(10328), 957-1022. https://doi.org/10.1016/s0140-6736(21)02141-3</li>
</ol>
</article>