Strengthening the mpox response: how do we balance pragmatism and equity in resource-constrained settings?

Mpox, previously neglected as an endemic zoonotic disease in West and Central Africa, has become a significant global threat following its second declaration as a public health emergency of international concern. With the growing number of cases, the region faces several challenges, particularly inadequate surveillance and diagnostics, and a lack of vaccine access. Drawing on lessons from public health emergency response in the Economic Community of West African States region, we aim to inspire a new vision with health emergency preparedness and response framework transformed for implementing mpox response to improve people's health and strengthen national, regional, and global health security. We provide insights into how pragmatism and equity considerations can guide short- and long-term overarching strategies and actions to achieve this vision, particularly in low-resource settings. We also identify sustained political commitments and investments at all levels of health governance as cross-cutting imperatives for controlling the outbreak. Specifically, vaccine access strategies (phased rollout, community-based distribution models and dose-sparing administration) and surveillance and diagnostics strategies (stigma-sensitive risk communication and community engagement, increased health workers and volunteers' training, and decentralised monitoring and testing) were highlighted as critical for optimal control. Based on this, we call for a strengthened mpox response that leverages local networks (e.g. community-based organisations, non-governmental organisations, and groups caring for men who have sex with men (MSM)/sex workers networks), the private sector, and digital solutions. To improve the coverage, impact, and sustainability of health and social interventions for this response, we emphasise a focus on at-risk populations (young children, MSM/sex workers, health workers/volunteers, contacts of cases), vulnerable populations (people living with HIV, people on immunosuppressive therapy, and pregnant women), and underserved communities (rural areas, hard-to-reach locations, and humanitarian settings), alongside a reformed global health architecture and strengthened regional and national health systems.