News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

Tompot blenny (Parablennius gattorugine)

News Flash 627

Weekly Snapshot of Public Health Challenges

 

Why humanitarians must act to end Israel’s genocide in Gaza

The European Union is dying in Gaza: The umpteenth EU refusal to sanction Israel fuels the killing fields in Palestine

WHO Issues Global Alert On ‘Fast-Moving’ Chikungunya Outbreak

WHO urges action on hepatitis, announcing hepatitis D as carcinogenic

World Hepatitis Day 2025 – Message from Charles Gore

New injection for easier prevention of HIV infection in the EU and worldwide

ViiV Healthcare and Medicines Patent Pool extend voluntary licensing agreement to enable access to long-acting injectable HIV treatment

Most people on ARVs stay on them — does our health system know that?

Human Papillomavirus and Cancer

Public Pharma: A Remedy for Drug Shortages

Forecasting the Fallout from AMR: Economic Impacts of Antimicrobial Resistance in Humans

AN2 Therapeutics and DNDi collaborate on clinical development of promising new oral compound to treat chronic Chagas disease

Governments ‘Backslide’ on NCD Commitments After Pressure from Unhealthy Industries

Rethinking Community Pharmacy: A Path To A Sustainable Model

Africa Aware: Strengthening Africa’s health security

What Is the Caregiver Crisis?

UNPO Denounces Ongoing Violations Against Naga People at the UN Expert Mechanism on the Rights of Indigenous Peoples (EMRIP)

HRR778. NOT SO FACETIOUSLY: CONSERVATIVES GO TO THE TABLE AT 6, LIBERALS AT 7. THAT IS ABOUT THEIR DIFFERENCE WITH RESPECT TO CAPITALISM. …AND WHAT ABOUT LEFTISTS?

Malnutrition in Nigeria killed 652 children in past six months, MSF says

SOFI 2025 Report Neglects Structural Causes of Hunger: Gaza Starves as Corporate Power Goes Unchecked

Global hunger declines, but rises in Africa and western Asia: UN report

What Does It Cost to Feed a Child? New Global Evidence on the Economics of School Meals

Progress still needed on food

The warning labels that could be coming for your crisps

Mining on the Rise as Clean Energy Demands Shifts Global Commodity Exports

How Clustering Multilateral Environmental Agreements Can Bring Multiple Benefits to the Environment

Environment ministers mull climate finance, Africa’s development future

Climate-responsive social protection: A primer for philanthropy

First reformulation of an inhaled medicine with environmentally friendly gas propellant

‘After Decades of Making Huge Profits, Companies Shouldn’t Be Allowed to Leave Behind a Toxic Legacy’

 

 

 

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

Dustbin-lid jellyfish (Rhizostoma pulmo)

News Flash 626

Weekly Snapshot of Public Health Challenges

 

Public consultation on The TRUST CODE SUPPLEMENT – A Global Code of Conduct for Research in Fragile Settings. The deadline for submitting your comments is 15 August 2025

Recycled SDRs: Lost in Transmission?

More than 100 aid, rights groups call for action as hunger spreads in Gaza

Joint Public Health Statement on Gaza: a united voice for health and humanity

Seville 2025: 5% for War, 0.25% for Life?  by Juan Garay

People’s Health Dispatch Bulletin #104: Global struggles for health sovereignty: from Palestine to Mexico

Social Medicine and Genocide

US rejects WHO pandemic changes to global health rules

DNDi 2024 Annual Report

Key Considerations for Inter-country Pooled Procurement of Health Products

Global childhood vaccination coverage holds steady, yet over 14 million infants remain unvaccinated – WHO, UNICEF

Polio Eradication in Pakistan by 2050: Innovations, Gaps, and the Forgotten Human Factor  by Muhammad Noman

14 million children did not receive a single vaccine in 2024, UN estimates

First mRNA vaccine for Marburg shows promise in animal trial

Superbugs could kill millions more and cost $2tn a year by 2050, models show

Supporting the successful elimination of malaria in Suriname

Timor-Leste certified malaria-free by WHO

Senegal joins growing list of countries that have eliminated trachoma

Substandard anticancer medications in clinical care settings and private pharmacies in sub-Saharan Africa: a systematic pharmaceutical investigation

 Valuing Medicines in Different Health Systems  by Andy Gray and Christiane Fischer 

Key HIV prevention drug could cost just $25 a year, finds study published in SUNS #10264 dated 18 July 2025

Gilead’s Voluntary License on Lenacapavir: Key Limitations of the License and Recommendations to Improve Access

Community-Based Interventions to Support HIV and AIDS Orphans and Vulnerable Children (OVC) in Africa: A Systematic Review

Stethoscopes on Hold: Exploring the Employment Crisis Among New Doctors in the Kurdistan Region of Iraq  by Goran Abdulla Sabir Zangana

HRR777. EVERY HISTORICAL EPOCH IS THE RESULT OF WHAT THE POWERFUL STATES DESIGNED AT EACH MOMENT

Socioeconomic inequalities in life expectancy in Australia, 2013–22: an ecological study of trends and contributions of causes of death

Beneath the Lullaby: A Mother’s Pain Unheard, Unseen, Unanswered

Health conditions among women in prisons: a systematic review

Millions go hungry in Nigeria as aid dries up, jihadists surge

FIAN Blog: Right to food rooted in territories but needs state support

Climate Change and Health Disasters/Risks in Nepal  by Damodar Adhikari 

World’s Major Courts Take Growing Role In Climate Fight

Climate Pressures are Redefining Macroeconomic Resilience in Asia & the Pacific

 

 

 

 

 

 

 

IN A NUTSHELL
 Editor's Note  The piece here is an excerpt from the final manuscript ‘Health Sector Disaster Management Handbook: Nepal’, just edited by the Author, which is soon going to print.  

As in the Executive Summary, the Handbook  ‘…serves as a comprehensive guide for enhancing Nepal’s health sector preparedness, response, recovery, and resilience in the face of disasters and public health emergencies. Given Nepal's unique geographical, socio-political, and environmental context, the health sector faces growing risks from natural hazards, climate change, disease outbreaks, and technological accidents…’  

As the Author maintains   ‘It is designed as a comprehensive, context-specific guide for health professionals, policymakers, emergency responders, development partners, and community actors seeking to build a robust and resilient health system that can withstand and respond to the multifaceted challenges posed by disasters’.

Please refer to the Author for in-depth information over of the entire work

By Damodar Adhikari

Executive Director SIMEX Hub

Nepal

Climate Change and Health Disasters/Risks in Nepal

 

Climate Change and Health Disasters

The impacts of climate change in Nepal are becoming increasingly evident, with rising temperatures, erratic rainfall patterns, and melting glaciers.

• Vector-Borne Diseases: Warmer temperatures and changing rainfall patterns expand the habitats of disease vectors like mosquitoes, leading to increased cases of malaria, dengue, and other vector-borne illnesses.
• Food Security: Erratic weather affects agricultural productivity, contributing to malnutrition and associated health issues.

Epidemics and Public Health Emergencies

Nepal’s public health system is periodically strained by outbreaks of infectious diseases.

• Cholera and Waterborne Diseases: Frequent outbreaks are linked to poor water quality and inadequate sanitation, particularly during floods.
• COVID-19 Pandemic: The global pandemic highlighted systemic vulnerabilities, such as limited critical care infrastructure, shortages of medical supplies, and inequitable healthcare access.

Conclusion

Nepal’s vulnerability to disasters stems from a combination of geographic, climatic, and socio-economic factors. Each type of disaster presents unique challenges to the health sector, necessitating a robust disaster management system. The following chapters will explore strategies for mitigating these risks, strengthening health system resilience, and ensuring effective disaster response and recovery.

Climate Change and Health Risks

Introduction

Climate change poses significant risks to public health, particularly in Nepal, where its diverse geography and socio-economic vulnerabilities amplify the effects. Rising temperatures, erratic rainfall patterns, and extreme weather events contribute to increased disease burdens, infrastructural damage, and significant strain on healthcare systems across the country.

Health Impacts of Climate Change

Over the past five decades, Nepal has experienced an average temperature increase of 0.06°C per year, with higher rates of warming observed in the Himalayan region and urban centers. This warming has intensified urban heat islands in cities like Kathmandu and Pokhara, leading to an increase in heat-related illnesses such as heatstroke and dehydration. Vulnerable groups including the elderly, outdoor workers, and those with pre-existing medical conditions are particularly at risk.

Monsoon floods regularly inundate large areas of the Terai region, affecting millions of people and disrupting essential health services. The devastating floods of 2024 impacted over 200 health facilities nationwide, including the complete submersion of the Susta Pari health post. In the aftermath of such floods, waterborne diseases such as diarrhea, cholera, and typhoid surge significantly, with cases rising by 30-40% in the affected areas.

Vector-borne diseases also pose a growing threat as climate change alters mosquito breeding patterns. In 2023, Nepal saw a surge in dengue infections with over 50,000 reported cases, largely driven by climate- induced environmental changes. Additionally, rising temperatures have expanded malaria transmission to higher altitude regions previously unaffected by the disease, posing new challenges for disease control.

Air pollution, especially in Kathmandu, frequently exceeds World Health Organization limits, worsening respiratory tract infections, asthma, and cardiovascular diseases. During dry seasons, wildfires and droughts increase particulate matter (PM2.5) in the air, resulting in a 20- 30% rise in respiratory hospitalizations.

Climate-Resilient Health Strategies

Figure: DRR portal

 

 To address these challenges, several climate-resilient strategies are essential. Urban areas should develop heatwave response plans by establishing cooling centers during peak summer months, running public awareness campaigns about hydration and heatstroke prevention, and implementing green urban planning initiatives that increase tree cover to mitigate heat island effects.

In the flood-prone Terai region, health posts need to be floodproofed by elevating infrastructure above historical  flood  levels,  equipping  facilities  with  solar-powered  emergency  backups  to  ensure uninterrupted services, and pre-positioning medical supplies in vulnerable areas to maintain readiness during disasters.

Strengthening early warning systems for climate-sensitive diseases is also critical. This includes enhancing disease surveillance through climate modeling to predict outbreaks of malaria, dengue, and cholera, implementing SMS-based alerts to inform high-risk communities, and expanding integrated vector management alongside community-based health interventions.

Conclusion

Climate change presents an urgent public health challenge that requires proactive and evidence-based responses. By integrating climate resilience into Nepal’s health systems, it is possible to mitigate the associated risks and ensure sustainable healthcare access for the country’s most vulnerable populations.

IN A NUTSHELL
Authors' Note
…A more pressing problem faces health systems in all countries, rich or poor: how to value a new medicine and decide whether to pay for it or not. That process, known as health technology assessment, requires access to the evidence of the benefits and harms associated with the medicine, compared with the alternative options that may already be used, and information about the costs incurred when using the medicine and the savings that may be achieved with its use. The costs, in particular, can be viewed from different perspectives. Considering only the costs borne by the health systems is justifiable, but ignores the costs that may be incurred by patients, their families and caregivers…

By Andy Gray*

and Christiane Fischer**

 

*Andy Gray, BPharm MSc (Pharm) PhD FPS FFIP

Division of Pharmacology, Discipline of Pharmaceutical Sciences, University of KwaZulu-Natal, Durban, South Africa

WHO Collaborating Centre on Pharmaceutical Policy and Evidence Based Practice

**Dr. med. Christiane Fischer is the first chairwoman of the People’s Health Movement Germany https://phmovement.de and teaches public health. She is the medical advisor to the MSK e.V. https://www.multiple-sklerose-e-v.de/

Valuing Medicines in Different Health Systems

 

That the health systems (governments and health insurers) in high-income countries can afford to pay more for new medicines that may bring important health benefits than the health systems in low- and middle-income countries seems obvious. That does mean, however, inequitable access to such medicines and other health technologies (such as diagnostic tests). It also obscures a very important point – that every health system, whether rich or poor, is facing demands for new medicines that are so expensive or so complicated to use that they exceed the capacity of the health system to pay for them.

Many new medicines, particularly for conditions such as cancer, require sophisticated diagnostic tests to identify the patients most likely to respond positively. A genetic test may be needed, for example, to detect a mutation that allows for a particular treatment to work, or which predicts a better outcome. Those tests may not be easily accessed in low- and middle-income countries.

Many new medicines also contain large molecules, such as proteins or antibodies. These biological medicines are more difficult to copy once the period of patent protection ends, making the entry of more affordable biosimilar versions less certain. The difference in prices between the original biological medicine and the biosimilar version may also be less than is seen with generic versions of small molecule medicines compared to their originator versions.

A more pressing problem faces health systems in all countries, rich or poor: how to value a new medicine and decide whether to pay for it or not. That process, known as health technology assessment, requires access to the evidence of the benefits and harms associated with the medicine, compared with the alternative options that may already be used, and information about the costs incurred when using the medicine and the savings that may be achieved with its use. The costs, in particular, can be viewed from different perspectives. Considering only the costs borne by the health systems is justifiable, but ignores the costs that may be incurred by patients, their families and caregivers.

While much progress has been made in making the evidence of benefits and harms as transparent as possible, far less is known about how the prices demanded by the pharmaceutical industry, for both original and follow-on products (biosimilars and generics), are determined. By registering clinical trials before they are conducted, the results that are finally announced and published in peer-reviewed journals can be compared with the planned protocols. Increasingly, medical journals encourage researchers to make the data that underpins their articles available to others. By contrast, the costs of doing those clinical trials, as well as the basic and pre-clinical research, and of bringing a commercial product to market are not transparent. One is left with the impression that the prices demanded are based on what the market will bear, rather than the actual costs of research and development and a reasonable return on investment. Governments and their health systems are also under pressure to agree to confidential pricing terms for new and expensive medicines, in order to make them available.

An example – multiple sclerosis

Valuing a medicine depends on the confidence with which the evidence of benefits and harms can be described. That is not always a simple task. Multiple sclerosis (MS) provides a useful example of the challenges facing health systems. MS is an inflammatory disease of the central nervous system (brain and spinal cord) which causes a loss of the fatty protective layer around nerves (the myelin sheath), resulting in damage and disability. Most patients are diagnosed with MS as young adults, and 2-3 times more female than male patients are affected. In most patients, MS presents as a relapsing–remitting condition.ⁱ  In other words, periods of acute symptoms (relapses) are separated by periods of fewer symptoms (remissions). Patients may enter remission without specific treatment, but may also suffer a relapse while on treatment. The extent to which MS is diagnosed varies dramatically across the globe. For example, while 280 000 MS patients have been identified in Germany (representing about 300 per 100 000 population), only about 5000 MS patients have been diagnosed in South Africa (or 8 per 100 000 population).ⁱⁱ While access to sophisticated diagnostic tests (such as magnetic resonance imaging) can explain some of the difference, other factors may well be at play. The exact causes of MS are not perfectly understood.ⁱⁱⁱ MS appears to be associated with a range of environmental (lifestyle), genetic and possible infectious triggers. Until that process is clearly understood, targeting the treatment is challenging.

While the treatment of acute episodes is better known, and relies on corticosteroid medicines which are off-patent, affordable and widely accessible, far less is known about the best options for long term treatment. The first treatments for MS were approved by medicines regulatory authorities in the early 1970s, but newer options have been approved as late as 2022. The comparative advantages of newer over older treatments remains unclear, despite these years of research and development.

The newer of these treatments, which are monoclonal antibodies, are available in all high-income countries, but in no low-income countries. The most important barrier to access remains the price demanded for these newer, patent-protected biological medicines. In addition, the adverse effects of some of the newer medicines, such as an increased risk of infections, may be more important in lower income countries where infectious disease burdens are still high. For example, an increased risk of tuberculosis would be a serious consideration in countries with high tuberculosis incidence, especially where drug-resistant forms are prevalent.

One way in which countries can start their discussions about whether to purchase or pay for medicines is to consult the World Health Organization (WHO) Model List of Essential Medicines.^iv

These are medicines which have been considered by an expert committee at WHO and which should be available in all health systems. In 2023, the WHO committee recommended adding three medicines for MS to the Model List – cladribine, glatiramer acetate and rituximab. However, it refused to add a newer biological medicine, ocrelizumab.^v It argued that there was a lack of evidence of the superiority of ocrelizumab over rituximab, which was already widely used and more affordable in several countries. All three MS treatments appear on the complementary portion of the Model List, as they require either specialised diagnostic or monitoring facilities, specialist medical care or specialist training to be used safely and effectively.

An example – cystic fibrosis

In 2025, the WHO expert committee was presented with proposals to include three new and very expensive medicines for the management of cystic fibrosis – elexacaftor, tezacaftor and ivacaftor.^vi Cystic fibrosis is a rare genetic disease which affects about 190 000 people globally. However, only 60% are diagnosed.^vii More than 80% of those who are undiagnosed live in low- and middle-income countries. Currently, the WHO Model List only includes pancreatic enzymes, which are a supportive treatment but do not address the cause of cystic fibrosis. The new immune modulator therapies have the potential to dramatically alter the course of the disease. If they are started early, patients with cystic fibrosis may live as long as the general population without the disease. While all the immune modulators are now under patent, the first generic versions may be available after 2027. More affordable access is therefore a possibility. It is not yet known how the WHO expert committee, which met in May 2025, has decided in respect of this application. A positive decision will place pressure on health systems to provide access to these expensive medicines immediately. Many will struggle to do so, until more affordable alternatives become available. In addition, treatment is likely to be needed lifelong.

A way forward

These two examples have shown how challenging it is for health systems to decide how much they are willing to spend on new and expensive medicines, especially where there is uncertainty about their benefits and harms. Two ways in which the decisions can be made easier would be:

1. to share the assessments of benefits, harms and costs and the ways in which health technology assessment bodies have modelled these considerations in order to get to a decision; and
2. to improve the transparency of pricing, and particularly the costs incurred in research and development (including the contributions made by governments and academic scientists), so that better judgments can be made about what a reasonable price would be, without hiding behind non-disclosure agreements and confidential agreements.

Both of these interventions can assist high-income countries to make better decisions, but they can also, if shared openly, assist low- and middle-income countries to build their own models.

Transparency ensures that those who supply new medicines do not have an unfair advantage over those who buy them).

 

References

ⁱ MS international federation https://www.msif.org/about-ms/ (access: 16.07.2025)

ⁱⁱ MS international federation, Atlas global epidemiology, https://atlasofms.org/map/global/epidemiology/number-of-people-with-ms (access: 16.07.2025)

ⁱⁱⁱ MS international federation, Resources, https://www.msif.org/resources/ (access: 16.07.2025)

^iv World Health Organisation, Model List of Essential Medicines, https://list.essentialmeds.org/(access: 16.07.2025)

^v World HealthOrganisation, Model List of Essential Medicines, recommendations, https://list.essentialmeds.org/recommendations/1349 (access: 16.07.2025)

^vi World HealthOrganisation, Model List of Essential, selction, https://www.who.int/groups/expert-committee- on-selection-and-use-of-essential-medicines/25th-expert-committee-on-selection-and-use-of-essential-medicines/a.11-elexacaftor-tezacaftor-ivacaftor-cystic-fibrosis (access: 16.07.2025)

^vii Guo J, King I, Hill A. International disparities in diagnosis and treatment access for cystic fibrosis. Pediatric Pulmonology. 2024/06/01;59(6) https://doi.org/10.1002/ppul.26954 (access: 16.07.2025)

IN A NUTSHELL
Author's Note
 

...What’s missing is not data or technical capacity—but political will, ethical clarity, and courage. The Seville Platform for Action announced 130 initiatives, but none establishes the kind of global tax justice framework SHEM and others have long demanded: a multilateral system to tax wealth, extractive profits, and digital monopolies, with revenues invested in regenerative public goods.

 In essence, Seville revealed a troubling asymmetry: an ever-expanding architecture to protect capital, and a shrinking one to protect life. Without enforceable public redistribution, climate resilience, universal healthcare, and equitable education will remain hostage to market volatility and elite priorities...

 By Juan Garay

Professor and Researcher in Ethics and Metrics of Health Equity (Spain, Mexico, Cuba, Brazil)

 Seville 2025: 5% for War, 0.25% for Life?

By the same Author on PEAH: see HERE and HERE

 

The Fourth International Conference on Financing for Development (FFD4), held in Seville in July 2025, was marked by grand rhetoric and a flood of lofty pledges. Yet despite the launch of numerous innovation platforms and voluntary coalitions under the so-called Seville Commitment, the conference left a gaping moral and political void: its failure to secure meaningful public redistribution for sustainable equity, especially through binding commitments on Official Development Assistance (ODA).

The numbers speak for themselves. ODA remains stalled at just 0.3% of donor countries’ GDP, far short of the long-standing 0.7% target. No new binding commitment was made in Seville to bridge this decades-old gap. Instead, the spotlight shifted to mobilizing private capital—through blended finance platforms, sustainability-linked bonds, and risk-sharing schemes aimed at enticing profit-driven investors into development spaces. While such mechanisms may produce limited benefits, they effectively outsource global equity to the market, turning rights into returns.

This omission becomes even more disturbing when set against other global spending priorities. At the recent NATO summit, member states agreed to raise military spending to 5% of GDP, citing geopolitical instability. The richest nations on Earth appear ready to spend trillions on weapons, yet they recoil at allocating even 0.7% of their wealth to support planetary wellbeing.

The recent Sustainable Health Equity Movement-SHEM webinar series on global income thresholds and redistribution has exposed the profound injustice behind this disparity. As outlined in these sessions, a minimum of 7% of global GDP must be redistributed annually to guarantee sustainable wellbeing and equity—preventing an estimated 15 million avoidable deaths per year. This would mean redirecting resources from countries with per capita GDPs above the “excess threshold” to communities suffering from ecological collapse and structural exclusion.

Seville did briefly acknowledge redistribution—by recommending that low-income countries raise domestic tax revenues to at least 15% of GDP, a long-standing IMF benchmark. Yet such expectations are deeply unfair in the absence of any serious commitment to global redistribution, especially from the wealthiest nations. These countries often lack the fiscal space, infrastructure, or political autonomy to reach those targets without external support—particularly in a global economy where tax rules still favor multinational corporations and extractive elites.

What’s missing is not data or technical capacity—but political will, ethical clarity, and courage. The Seville Platform for Action announced 130 initiatives, but none establishes the kind of global tax justice framework SHEM and others have long demanded: a multilateral system to tax wealth, extractive profits, and digital monopolies, with revenues invested in regenerative public goods.

In essence, Seville revealed a troubling asymmetry: an ever-expanding architecture to protect capital, and a shrinking one to protect life. Without enforceable public redistribution, climate resilience, universal healthcare, and equitable education will remain hostage to market volatility and elite priorities.

We are witnessing a world where less than 0.3% of the surplus income hoarded by wealthy nations is dedicated to lifting those below the global minimum threshold of wellbeing. Meanwhile, military spending outpaces ODA by a factor of 20 to 1. Global governance remains oligarchic, as exemplified by the UN Security Council, enabling wars, genocides, and the protection of privilege through force.

SHEM affirms that wellbeing cannot be commodified. Equity is not a side effect of financial engineering—it is a right that requires structural redistribution. The tools exist. What the world needs now is a profound moral realignment: from profit to planet, from militarism to mutual care, from charity to justice.

For reference of the analysis and proposals of global tax Justice for global wellbeing in sustainable equity see:

https://www.peah.it/2023/12/12800/

https://www.peah.it/2024/12/14117/

SHEM webinars : https://www.sustainablehealthequity.org/webnair

 

Editor's Note
My professional relationship with Dr Brian Johnston  dates back four years ago when I published on PEAH platform a contribution article by him as the first of a series of far-reaching pieces spanning in critical view from COVID-19 to future pandemics and AI perspectives and challenges at the intersection of human, animal and environmental contexts in today’s arena

Letter of Endorsement

 

Dear Friends and Colleagues in the PEAH network, do you need an excellent data analyst, who can create Power BI dashboards, write reports and needs assessments, do complex statistics, including regression analyses and perform high quality research?

In this connection, let me suggest Dr Brian Johnston as a strong PEAH collaborator over a number of years

https://www.peah.it/2024/10/the-power-of-ai-for-health-inequalities

Please refer to his LinkedIn profile at www.linkedin.com/in/brianrjohnston/ for details of his skills and experience. I highly recommend his abilities.

Please contact Brian by e-mail on brjohnston_uk@yahoo.co.uk or by mobile on +44(0)7590 256190 to discuss opportunities.

Thank you. Kind regards,

Daniele Dionisio,

Head of the research project Policies for Equitable Access to Health (PEAH)

Member, European Parliament Working Group on Innovation, Access to Medicines and Poverty-Related Diseases

Former Director, Infectious Disease Division, Pistoia Hospital, Pistoia (Italy)

http://www.peah.it/

IN A NUTSHELL
Author's Note
The employment crisis among newly graduated doctors in the Kurdistan Region of Iraq (KRI) reflects broader structural challenges in healthcare workforce management across LMICs. While medical graduates are being produced at rates exceeding available positions, public sector hiring has slowed due to austerity measures and financial constraints. This mismatch leads to prolonged job searches, volunteer-based work, and shifts to non-medical fields, with nearly half of employed doctors in KRI working outside the medical profession. The expectation of prior experience creates a significant entry barrier for new doctors, further exacerbating unemployment trends.

A critical consequence of this paradox is the increased migration of doctors from LMICs to higher-income countries in search of stable employment and professional development opportunities

Stethoscopes on Hold: Exploring the Employment Crisis Among New Doctors in the Kurdistan Region of Iraq

 

Despite a global shortage of healthcare workers, many low- and middle-income countries (LMICs), including those in the Middle East and North Africa (MENA), paradoxically face high unemployment rates among doctors and healthcare professionals (Hutchinson et al., 2025). This issue arises due to inefficient workforce planning, economic constraints, and mismatches between medical education and labor market demands. In many cases, newly trained doctors struggle to find employment while healthcare systems remain understaffed.

Retention challenges persist, and one of the key concerns is the difficulty in keeping medical professionals engaged in their home countries. A review of retention strategies found that incentives such as financial support, compulsory service requirements, and career development programs can help, but no single method proved universally effective. Meanwhile, brain drain remains a pressing issue in MENA, where thousands of doctors migrate to higher-income countries seeking better opportunities (Al Saraf & Garfield, 2008; Chikanda et al., 2014; Mullan, 2005).

In Iraq and the Kurdistan Region, healthcare workforce challenges are exacerbated by economic instability and political tensions (Tawfik-Shukor & Khoshnaw, 2010). While there is an oversupply of medical graduates, austerity measures and budget constraints have limited job creation, leading to unpaid or volunteer-based healthcare work (Zangana & Muhammad, 2024) Many graduates struggle to find secure employment in public hospitals, preferring public sector roles for perceived stability, but financial hardships have made consistent hiring difficult. In Kurdistan, female healthcare workers are disproportionately affected by unpaid positions, highlighting systemic inequities.

Job dissatisfaction among medical professionals in LMICs often stems from poor working conditions, low salaries, and limited career progression (AL-Abrrow et al., 2021). A systematic review indicated that improving salaries and offering career development opportunities could enhance retention rates (Willis-Shattuck et al., 2008). However, in MENA, structural employment barriers persist due to economic constraints restricting government healthcare hiring, mismatches between medical education and labor market needs, political instability disrupting workforce planning, and limited job creation forcing professionals into informal or volunteer work.

A particularly concerning phenomenon in some LMICs, including Sierra Leone and parts of Iraq, is the existence of unpaid health workers. Many rely on informal coping strategies, worsening healthcare inequities and workforce instability. Without effective policies to absorb excess medical graduates, doctor unemployment remains a critical issue that requires urgent intervention.

The problem of unemployed doctors and healthcare workers in LMICs and MENA is multifaceted, requiring targeted interventions in workforce planning, financial incentives, and healthcare system reforms. Countries must balance medical education with labor market demands while ensuring fair employment conditions for healthcare professionals. Future research should evaluate retention strategies and address systemic barriers to employment.

Methods

This study employed a cross-sectional design using an online survey to explore the employment status, career trajectories, and psychosocial impact of unemployment among newly graduated doctors in the Kurdistan Region of Iraq (KRI).

Survey Design and Distribution

A structured questionnaire was developed and hosted on Google Forms. The survey was designed to capture both quantitative and qualitative data, including demographic information, employment status, job search duration, mental well-being, perceived family/community support, and willingness to change careers or relocate.

The Google Form was disseminated via a WhatsApp platform specifically created for unemployed doctors in the KRI, comprising 627 newly graduated doctors actively seeking employment in the public sector. Participation was voluntary and anonymous, and no incentives were offered for completion.

Data Collection and Response Rate

The survey remained open for responses for a defined period, during which 241 doctors completed the questionnaire. This corresponds to a response rate of approximately 38.44% (241 out of 627).

Data Analysis

Quantitative data collected through the Google Form were exported into Microsoft Excel for cleaning, coding, and analysis. Descriptive statistics were calculated to assess demographic patterns, employment distribution, search duration, and mental well-being indicators. Categorical variables were summarized using counts and percentages, while continuous variables (e.g., search duration) were analyzed using measures of central tendency (mean and median). Chi-squared tests and Cramer’s V were used to explore potential associations and correlations between key variables. Additionally, open-ended responses were reviewed to identify recurring themes and systemic challenges.

Results

Demographic Trends in Unemployment

Analysis of age-related unemployment patterns indicates that doctors aged 24 years are the most affected group across the dataset. Gender-based analysis reveals that 25-year-old males in Erbil experience the highest unemployment rate. When stratified by governorate, Erbil emerges as the region with the highest overall unemployment among doctors.

Employment Patterns and Sectoral Distribution

Employment distribution data show that approximately 48.21% of employed doctors are working in the medical field, while 51.79% are employed in non-medical fields. This indicates a slight predominance of non-medical employment among doctors. Among non-medical roles, Marketing and Education are the most frequently reported sectors, with Marketing being the most prevalent.

Job Search Duration

The average duration that doctors have been actively searching for a medical-related job is approximately 7.16 months. This average is marginally higher than the median, suggesting a right-skewed distribution where a subset of doctors experience prolonged periods of unemployment. A bar chart visualization confirms these central tendencies, aiding in comparative interpretation.

Willingness to Relocate

An anomaly was noted in the dataset where 0.0% of unemployed doctors were reported as willing to relocate. This figure is likely due to a coding error involving incorrect column usage (‘Have you thought about changing careers due to unemployment?’ was used instead of ‘Would you consider relocating outside the Kurdistan Region or Iraq for a medical job?’). A Chi-squared test returned a p-value of 1.0, indicating no statistically significant association between employment status and willingness to relocate. However, recalculations with corrected variables are needed for accurate interpretation.

Mental Well-being and Social Support

Unemployment has a pronounced negative effect on doctors’ mental well-being:

• 198 doctors reported being very negatively impacted,
• 39 doctors reported a somewhat negative impact, and
• Only 3 doctors reported no impact on their mental health.

Regarding perceived family and community support:

• 111 doctors reported feeling somewhat negatively supported,
• 84 doctors reported no impact, and
• 38 doctors reported feeling very negatively supported.

A weak positive correlation was observed between perceived support and mental well-being (Cramer’s V = 0.223), indicating that while community support may play a role, other factors also significantly influence psychological outcomes. Notably, doctors experiencing a very negative mental health impact were found across all levels of perceived support, with the largest group feeling only somewhat supported.

Career Change Considerations

A substantial proportion of doctors reported considering a career change:

• 40% of unemployed doctors and
• 97% of employed doctors

have thought about changing careers. The difference between the two groups is only 0.43%, suggesting that employment status is not the primary driver behind this decision. This points to broader systemic or professional dissatisfaction affecting both groups similarly.

Regional Variation in Job Search Duration by Age

Correlation analysis revealed significant regional variability in how age relates to job search duration. For instance:

• In Sulaymaniyah, a positive correlation was observed, indicating that older doctors tend to search longer for jobs.
• In Erbil (Hawler), a negative correlation was identified, suggesting that older doctors find jobs more quickly.

These patterns may reflect differences in local job markets, socio-economic conditions, or access to professional networks. Further investigation is warranted to understand these dynamics and inform the design of region-specific employment support programs.

Structural Barriers to Employment

Open-ended survey responses identified “experience” as the most commonly cited challenge and a key contributor to unemployment. Respondents also pointed to systemic barriers such as the role of government ministries, inequities between public and private sectors, and broader political factors. Text analysis also revealed a high frequency of generic terms (e.g., “the,” “in,” “not”), indicating the need for refined natural language processing techniques such as n-gram analysis or topic modeling to uncover deeper themes and actionable insights.

Discussion

The employment crisis among newly graduated doctors in the Kurdistan Region of Iraq (KRI) reflects broader structural challenges in healthcare workforce management across LMICs. While medical graduates are being produced at rates exceeding available positions, public sector hiring has slowed due to austerity measures and financial constraints. This mismatch leads to prolonged job searches, volunteer-based work, and shifts to non-medical fields, with nearly half of employed doctors in KRI working outside the medical profession. The expectation of prior experience creates a significant entry barrier for new doctors, further exacerbating unemployment trends.

A critical consequence of this paradox is the increased migration of doctors from LMICs to higher-income countries in search of stable employment and professional development opportunities. Countries like the UK have historically relied on international medical graduates to fill gaps in their healthcare systems. However, the accelerating departure of newly graduated doctors from regions like KRI will likely intensify competition for positions abroad, while simultaneously deepening domestic shortages in specialist training pathways.

This trend presents a dual challenge. On one hand, LMICs face a brain drain, losing skilled professionals who could contribute to national healthcare systems. On the other hand, higher-income countries such as the UK, which are already struggling to recruit doctors into specialist posts, particularly in the NHS, may see an influx of overseas doctors seeking these positions. While this might alleviate certain workforce shortages in the short term, it does not address the systemic recruitment and retention challenges faced by both LMICs and high-income healthcare systems.

Many unemployed doctors also report severe negative mental health effects, signaling high levels of stress and professional dissatisfaction, which often act as push factors encouraging migration. While international relocation is not widely pursued within KRI due to financial and logistical constraints, it is likely that the worsening employment outlook will increase migration rates over time.

Conclusion

The growing mismatch between medical education and labor market demands in LMICs, including KRI, is fueling a cycle of unemployment, career transitions outside medicine, and increased doctor migration. Without systemic reforms to align workforce planning with graduate output, newly trained doctors will continue seeking employment abroad, further exacerbating domestic shortages in specialist healthcare roles. Higher-income countries like the UK, struggling to recruit doctors into critical specialty posts within the NHS, may see an increased influx of international medical graduates. However, without addressing broader retention challenges and career progression concerns, both LMICs and high-income countries will remain caught in a cycle of workforce instability.

To mitigate these issues, policymakers must invest in sustainable job creation, targeted workforce planning, and retention strategies within LMICs to reduce forced migration due to unemployment. Simultaneously, high-income countries must implement policies that ensure international medical graduates receive fair career progression opportunities without perpetuating global inequities in healthcare staffing. Future research should focus on longitudinal tracking of doctor migration patterns, analyzing how workforce shortages evolve globally and identifying sustainable solutions for both sending and receiving healthcare systems.

 

References

Al Saraf, H., & Garfield, R. (2008). The Brain Drain of Health Capital: Iraq as a Case Study. In Health Capital and Sustainable Socioeconomic Development.

AL-Abrrow, H., Al-Maatoq, M., Alharbi, R. K., Alnoor, A., Abdullah, H. O., Abbas, S., & Khattak, Z. Z. (2021). Understanding employees’ responses to the COVID-19 pandemic: The attractiveness of healthcare jobs. Global Business and Organizational Excellence, 40(2), 19–33. https://doi.org/10.1002/joe.22070

Chikanda, A., Bourgeault, I. L., & Labonté, R. (2014). Brain Drain and Regain: The Migration Behaviour of South African Medical Professionals. https://www.researchgate.net/publication/280444795

Hutchinson, E., Hutchinson, E., Kiwanuk, S., Muhindo, R., Nimwesiga, C., Balabanova, D., Mckee, M., & Kitutu, F. E. (2025). The paradoxical surplus of healthcare workers in Africa: the need for research and policy engagement. In European Journal of Public Health (Vol. 34). https://academic.oup.com/eurpub/article/34/Supplement_3/ckae144.269/7844942

Mullan, F. (2005). The metrics of the physician brain drain. The New England Journal of Medicine, 17(353), 1810–1818. https://doi.org/10.1056/NEJMsa050004

Tawfik-Shukor, A., & Khoshnaw, H. (2010). The impact of health system governance and policy processes on health services in Iraqi Kurdistan. BMC International Health and Human Rights, 10, 14. https://doi.org/10.1186/1472-698X-10-14

Willis-Shattuck, M., Bidwell, P., Thomas, S., Wyness, L., Blaauw, D., & Ditlopo, P. (2008). Motivation and retention of health workers in developing countries: A systematic review. BMC Health Services Research, 8. https://doi.org/10.1186/1472-6963-8-247

Zangana, G., & Muhammad, A. K. (2024). Health Workforce Shortages and Surpluses: The Case of Unsalaried Workers in Kurdistan Region of Iraq. https://doi.org/10.21203/rs.3.rs-4682754/v1

 

 

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By the same Author on PEAH

Navigating the Labyrinth: Addressing the Structural Challenges for IMGs in the UK Healthcare System  

 

 

 

 

IN A NUTSHELL
Author's note
Pakistan, despite decades of focused eradication efforts, remains one of the few countries where polio continues to threaten children’s futures. As we assess progress toward eradication by 2050, this article offers a realistic and evidence-based review of the innovations introduced and the ground-level challenges that persist. While digital tools, better vaccines, and microplanning have evolved, a critical human factor is often neglected—the grossly inadequate incentives for frontline workers, supervisors, and Union Council staff, who are central to campaign execution. Low per diems, multiple job burdens, weak accountability, lack of third-party verification, and an uncommitted EPI infrastructure all contribute to persistent virus transmission. Surveillance gaps, mobile populations, refusals, and environmental contamination continue to keep Pakistan in a cycle of near-eradication followed by resurgence. The article urges a structural reset—prioritizing people over systems—to make true eradication a reality by 2050

By Muhammad Noman

Healthcare System, CHIP Training and Consulting

Quetta, Balochistan Pakistan

Polio Eradication in Pakistan by 2050

Innovations, Gaps, and the Forgotten Human Factor

Introduction: Where We Stand in 2050

Polio was once nearly eradicated in Pakistan, with zero reported cases in select years. However, by 2050, it is clear that the virus has not been eliminated sustainably. Despite all the tools available—GPS tracking, digital microplans, biometric attendance, and live dashboards—the program still falters due to deep-rooted human resource and incentive issues. This review aims to critically analyze what has worked, what has not, and what needs to change permanently.

The Backbone Under Strain: Frontline Workers

Frontline workers (vaccinators) are the face of the campaign, knocking on doors, facing refusals, traveling long distances, and vaccinating millions of children each month. However, their role is dangerously undervalued:

• Per diems are as low as Rs. 500–800 per day, which does not match inflation or transportation costs.
• Many vaccinators have been part of the campaign for over a decade but remain on temporary contracts, with no job security, benefits, or promotion path.
• To survive, they work multiple jobs—as domestic help, schoolteachers, or in local markets—causing fatigue and divided attention during campaigns.
• Demoralization is rampant. Many feel they are “used only for polio,” with no support for long-term health career development.

🔴 Recommendation: Frontline workers must be paid at least a living wage, given official recognition, and enrolled in formal health workforce pathways.

Supervisors: Multi-tasking Without Recognition

Supervisors (Area In-Charges or UC-level monitors) are expected to oversee 20–25 teams, ensure data accuracy, resolve refusals, report in real-time, and submit daily activity reports. However:

• Their incentives are barely Rs. 1,200–1,500 per day, while their responsibilities are disproportionately high.
• Many are working as teachers or in private jobs simultaneously, with supervision conducted “on the phone” or “via WhatsApp” rather than on-site.
• There is no structured training or certification, despite the program demanding professional-level data handling and team management.
• Supervisors face blame for failures, but rarely receive appreciation for improved coverage or breakthrough results in refusal areas.

🟡 Recommendation: Supervisors must receive salary-based contracts, fuel allowances, performance bonuses, and leadership training to remain committed and accountable.

Union Council Staff: The Neglected Core

Union Council Medical Officers (UCMOs) and UC Polio Officers (UCPOs) are responsible for the entire microplanning, coordination, and logistics chain in their areas. But:

• Their monthly incentives are often as low as Rs. 15,000–20,000, which does not reflect their workload.
• They are required to coordinate with multiple stakeholders (DHOs, NGOs, WHO, EOC, community leaders), yet often operate without proper offices or transport.
• Many UCMOs prefer to focus on private practice or NGO consultancy work where earnings are better, leaving polio responsibilities neglected.
• Frequent turnover and non-permanent positions affect institutional memory and long-term planning.

🟠 Recommendation: Union Council-level staff should be moved to full-time, salaried positions, with career incentives tied to performance in both polio and broader immunisation goals.

Weak Surveillance: The Invisible Failure

Surveillance is the foundation of polio eradication. Unfortunately, surveillance officers and assistants are often:

• Untrained or minimally trained, relying on outdated tools.
• Not motivated to conduct community-based AFP case investigations.
• Under pressure to show high performance, leading to inflated or delayed reports.

This weak surveillance results in: – Late detection of virus transmission. – Silent circulation in areas assumed to be “cleared.” – Positive environmental samples being dismissed without credible response, particularly in areas with large migrant and mobile populations.

⚠️ Note: Poor staff commitment directly weakens the surveillance framework. Without human-centered reforms, data reliability will remain questionable.

Migrants, Mobility, and Environmental Risk

Even in districts with 95%+ reported coverage, environmental samples show poliovirus presence—mainly due to:

• Underserved mobile groups: Afghan refugees, nomadic tribes, brick kiln workers, and seasonal migrants.
• No long-term inclusion strategy: These populations are still not part of EPI routine coverage.
• Transit teams are underpaid, unmotivated, and lack multilingual skills to interact with mobile families.

Without engaging these hard-to-reach populations, polio continues to travel silently across provincial and district borders.

No Third Party, No Trust

Campaigns are still reported as “successful” even when ground teams know the reality is otherwise. This is because:

• Internal monitoring is politically and managerially influenced.
• There is no independent body to verify data, assess staff honesty, or analyze refusal quality.
• This leads to false assurance, misdirected resources, and continued transmission.

🔭 Solution: Establishing an independent third-party monitoring system, possibly at the provincial level, is critical for unbiased feedback and accountability.

Community Trust and Communication Failures

Even after decades, refusal remains a leading challenge. This is due to:

• Repeated, one-way communication: “Vaccinate or else” has replaced respectful dialogue.
• No incentives or visible benefits to compliant families.
• Lack of health education and follow-up by trained female social mobilizers.

Community engagement needs to evolve from campaign messaging to genuine public health conversations.

Incentive Policy Failures: A Root Cause, Not a Side Issue

Despite the billions spent on polio eradication in Pakistan since 1988, the program has consistently failed to design a sustainable and fair incentive system for its ground-level workforce. This single failure has led to a chain of consequences:

❌ Short-Term Fixes, Long-Term Demoralization

• Per diems are still based on decades-old formulas.
• No annual revision mechanisms.
• Temporary hiring creates insecurity and weak motivation.

⚖️ Inequity Within the System

• Same per diem for lowland, urban, and highland, rural workers.
• No hardship allowance for conflict-prone zones.

📉 Consequences:

• Poor morale, high turnover, fake reports, and missed settlements.

✅ Long-Term Solution: Introduce a tiered, performance-based incentive policy adjusted for geography, workload, and years of service.

Comparative Case Study: Lessons from Nigeria

Nigeria was declared polio-free in 2020. Key strategies included: – Fixed stipends, not fluctuating per diems. – Local government ownership of staff payment and monitoring. – Full-time, trained, and identified frontline staff.

Pakistan can learn from this model by building trust, stability, and responsibility into the system.

Sustainability Crisis: Can We Keep Doing Campaigns Forever?

Pakistan continues to run 10–12 campaigns per year, leading to: – Community fatigue and resistance. – Routine immunisation being neglected. – Huge operational costs without long-term benefit.

🛍️ Future Focus: Transition from vertical campaigns to integrated, routine-based health delivery.

Vision 2050: A Realistic Roadmap for Pakistan

✅ 1. Revamp Incentives

• Living wages, regular reviews, hardship allowances.

✅ 2. Integrate Workers into Health System

• Absorb into EPI, nutrition, maternal-child health services.

✅ 3. Independent Monitoring

• Neutral oversight with real-time and community-level checks.

✅ 4. Integrated Campaigns

• Bundle services (polio, deworming, Vitamin A, etc.).

✅ 5. Build Trust Locally

• Engage imams, elders, teachers, and female mobilizers.

✅ 6. Focus on High-Risk Populations

• Mobile health vans, transit teams, and culturally competent outreach.

Conclusion: It’s Not a Vaccine Problem—It’s a System Problem

By 2050, Pakistan has the technology, the funds, and the tools. But polio will not end until the system values the people who deliver the vaccine. Frontline workers, overburdened supervisors, and overlooked UC staff are not just implementers; they are the foundation. The eradication of polio demands not just injections but investment in human dignity, fairness, and long-term vision.