IN A NUTSHELL
Author's Note 
The Decade Dividend outlines a bold strategy for low and middle-income countries: universal age-10 health screenings synced with national censuses, followed by lifelong decennial certifications.

This approach targets the critical preadolescent window when 70-80% of chronic disease risks lock in, using proven frameworks like WHO's GAMA indicators and Zimbabwe's Y-Check pilot (90% issue detection at USD 47/child). Real-world successes such as Vietnam's 95% NTD coverage, Singapore's Healthier SG (700K enrollments via 15% co-pay waivers), provide operational blueprints, with digital infrastructure enabling USD 5-10/decade scalability.

Economic modeling projects 1-2% annual GDP gains through preserved human capital, timed perfectly for WHA 2026 adoption via USD 500M G20 catalytic funding. A concrete Vietnam 2027 pilot (1M students, 10 provinces) offers immediate testability, transforming childhood health deficits into national economic engines

By Philip J. Gover, BA, MA, MPH, FCMI, FRSPH

Cooperation Works (Cambodia)

https://www.cooperation.works

philip.gover@cooperation.works

Note:   Developed through consultations with 1,000+ urban and rural residents via Cooperation Works' Citizen Health Panel.

Pre-peer review draft – comments welcome.

For partnership opportunities, contact philip.gover@cooperation.works

By the same Author on PEAH: see HERE

The Decade Dividend

 

The Decade Dividend proposes universal age-10 health screening that is integrated with the national censuses in low and middle-income countries (LMICs). Targeting the developmental window when 70-80% of chronic disease risk solidifies, the protocol detects stunting, NTDs, anaemia, vision impairment, and drowning/climate risks at USD 3-12/child.

GAMA’s 36 adolescent health indicators support this approach.  A proposed Vietnam 2027 pilot could target 1M students across 10 provinces, aiming for 85% participation and 15% high-risk yield.  M&E framework tracks SDG 2.2, 3.2, 3.3 via census infrastructure.  Economic returns could return 1-2% annual GDP growth via preserved human capital (World Bank modelling). WHA 2026 resolution + USD 500M G20 fund enables 50-LMIC rollout by 2028.

 

1.  Introduction – Paradigm Shift to Prevention

Current public health systems remain largely reactive. They address illness and disease management, rather than preventing it at its source. This underinvestment in both early and prevention-based health systems creates structural deficits across lifetimes and generations.

Around the world, 150.2 million children under five suffer stunting from malnutrition (World Health Organization [WHO], 2025a). This predisposes them to diabetes, cardiovascular disease, and diminished productivity in adulthood. Neglected tropical diseases (NTDs) afflict 1.495 billion people globally who require interventions (World Health Organization [WHO], 2025b). Schistosomiasis alone causes organ damage and cognitive impairment in early life. Drowning (over 300,000 lives annually) remains the leading cause of death for children under five in low-resource settings, with survivors often facing lifelong neurological disability (World Health Organization [WHO], 2024; Centers for Disease Control and Prevention [CDC], 2023).

Despite decades of targeted programmes, existing health infrastructures typically treat the consequences of poor early health at the expense of the root cause. A child experiencing malnutrition or NTD exposure at age five carries double or triple the risk of diabetes by age 40. Survivors of near-drowning often develop epilepsy or cognitive deficits that reduce lifetime earnings by one-fifth (Victora et al., 2008; Lancet Commission on Drowning, 2024). In both low and middle-income countries (LMICs), soil-transmitted helminth infections depress school performance and entrench poverty cycles. They collectively cost economies 1–2% of gross domestic product (GDP), per World Bank health-capital modelling, through lost productivity and healthcare spending (Bloom et al., 2019).

Adopting statutory, universal health checks at age 10 would serve dual ends. Timed one to two years before national censuses, they follow with decennial health certifications across the life course. This approach identifies preventable disease risk in the preadolescent window. It establishes a lifelong rhythm of preventive engagement, which if the history of public health has anything to tell us, is largely overdue. Age 10 marks an ideal intersection of development and data utility. Simple, school-based assessments capture nutrition gaps, cognitive and physical delays, NTD markers such as anaemia, and drowning risks amplified by climate-driven flooding (Lancet Countdown on Health and Climate Change, 2024). Aligning these screenings with census cycles generates dynamic population-level health datasets for national planning precision.

Projected benefits include 20–30% reductions in chronic disease incidence (Cohen et al., 2022), per meta-analysis. They encompass lower adult absenteeism and employment expansion in screening administration, telehealth, and longitudinal data analytics (García et al., 2016; Gómez-Cotilla et al., 2024). Meta-analyses estimate USD 7–13 per dollar invested in early interventions of this scale, drawing from historical evidence such as Perry Preschool and recent preventive health economic models (García et al., 2016; Gómez-Cotilla et al., 2024).

This paper presents the Decade Dividend. It reclaims economic and social returns of prevention through longitudinal health engagement, with integrated monitoring and evaluation frameworks tracking progress toward SDG targets. The Decade Dividend can impact distinct sections of the childhood disparity burden.  Age-10 checks and decennial certification design encompass economic outcomes evaluation that can front run a global feasibility assessment.  As such, a policy call to pilot the approach is presented.  Meaningful evidence demands a transition from reactive treatment to proactive prevention with digital elements remaining strictly compliant with national data-protection frameworks.

2.  The Burden of Childhood Health Disparities

150.2 million stunted children (51% Asia; SDG2 off-track by 46 million), 1.495 billion needing NTD interventions (funding down 41% 2018-2023), 300,000 annual drownings, These converging crises and more, cost economies far in excess 1-2% GDP annually (WHO, 2025a,b).

Overview: Scale of the Problem

The Decade Dividend addresses early health inequities that evolve into national economic liabilities. Around the world, 150.2 million children under five routinely experience stunting due to malnutrition (World Health Organization [WHO], 2025a). This early insult to health and wellbeing permanently alters metabolic, cognitive, and physical development. 1.495 billion people, primarily in low and middle-income countries (LMICs) require interventions against neglected tropical diseases (NTDs) (World Health Organization [WHO], 2025b). These diseases blunt childhood growth and educational attainment. Childhood drowning claims over 300,000 lives annually, mostly among children under five in low-resource settings, with survivors often sustain long-term neurological injury (World Health Organization [WHO], 2024).

The burden of childhood disparity, converge in predictable patterns. Poverty heightens vulnerability to both undernutrition and obesity. This establishes a pathway from childhood deprivation to adult-onset diabetes, cardiovascular disease, and reduced cognitive capital. Each stunted or chronically ill child is the stepping stone to lost productivity that is valued, increased long-term healthcare needs, pressure and costs, and diminished future tax revenues.

Malnutrition and Obesity: Dual Pathways to Chronic Disease

Malnutrition and obesity form the fundamental life-course pipeline from childhood hardship to adult chronic disease. Longitudinal studies, including the Brazilian birth cohorts, show clearly that early undernutrition doubles to triples the risk of type 2 diabetes and cardiovascular disease by middle age (Victora et al., 2008). Chronic energy deficits reprogram metabolism. Early excess weight accelerates insulin resistance and hypertension. Both set the stage for lifelong metabolic syndrome.

Malnourished children suffer 10-15% cognitive deficits, translating to lower school performance and ~20% reduced adult earnings (Grantham-McGregor et al., 2007). Childhood obesity correlates with poorer executive function and decision-making in later life. These deficits multiply across decades. Today’s malnourished or obese child becomes tomorrow’s worker who faces chronic illness, curtailed productivity, and higher healthcare needs and dependence.

NTDs: Silent Productivity Killers

Neglected tropical diseases erode human capital through quieter channels. Parasitic infections such as soil-transmitted helminths and schistosomiasis infect more than a billion children worldwide. They lead to chronic anaemia, intestinal inflammation and growth impairment. Soil-transmitted helminths alone account for nearly 200 million missed school days annually. This lowers adult earnings by 20–30% through lasting cognitive effects.

In schistosomiasis-endemic zones, heavily infected children show reduced physical work capacity in adulthood. Farm labour productivity declines by up to 40% (Victora et al., 2008; WHO, 2025b). Mass deworming costs approximately USD 0.50 per child. Yet underinvestment persists. High-burdened nations face estimated gross domestic product (GDP) losses of 1–1.5%, per World Bank health-capital modelling.

Drowning: Overlooked Neurodevelopmental Toll

Environmental hazards, especially drowning, impose a preventable neurological burden beyond infection and malnutrition. Drowning remains the leading cause of mortality for children under five in many low-income settings. However, survivors often experience brain hypoxia, which can contribute to epilepsy, cognitive delay, or motor impairment in roughly 10–20% of cases (Lancet Commission on Drowning, 2024). Studies from Bangladesh and Vietnam document adult income losses of 15–25% among childhood near-drowning survivors.

Lifelong disabilities raise public spending on healthcare and social support. They diminish workforce participation. Simple community interventions include swimming instruction, barriers around water hazards, and caregiver supervision. Proven examples include community swim-safety programmes in Cambodian and sub-Saharan drowning hotspots (Hile Teuk Kampuchea, NSRI). These grassroot and national initiatives have proven effective but remain unevenly scaled across high-burden regions.

Economic and Intergenerational Price Tag

Childhood malnutrition, NTDs, and drowning exact a global economic penalty in the trillions. Poor health in early-life can lower national GDP by at least 1–2% annually. This equals USD 1–4 trillion per year in combined medical, educational, and productivity losses (Bloom et al., 2019). High-burden countries lose up to 1.5% of GDP to NTDs alone. Post-drowning disability also adds millions in special-education and welfare costs.

These deficits persist across generations. Undernourished mothers give birth to low-birth-weight infants. These face elevated risks of metabolic and cognitive impairment. This perpetuates cycles of poverty and disease (Victora et al., 2008). The cumulative effect contracts workforces, depletes skills, and escalates fiscal pressure on health and social systems.

Climate Change Synergies

The Decade Dividend framework gains added urgency when viewed through the lens of climate change. Rising temperatures and extreme weather exacerbate the foundations and risks that this model targets. Increased flooding and stagnant water expand schistosomiasis and soil-transmitted helminth transmission zones; drought intensifies malnutrition; and more frequent extreme rainfall events drive childhood drowning spikes in low-lying LMICs (IPCC, 2023; Lancet Countdown on Health and Climate Change, 2024).

Modelling by the Lancet Countdown on Health and Climate Change (2024) projects that without integrated prevention, climate-sensitive NTDs could expose an additional 200 million people by 2030, while stunting prevalence in sub-Saharan Africa and South Asia may rise 5–10% due to crop failures. Near-drowning incidents linked to flash floods already contribute significantly to the annual drowning toll.

Age-10 screening offers a natural integration point. Simple environmental-risk questions (“household proximity to seasonal flood zones?”) plus anaemia and growth checks can flag children for climate-smart packages: deworming + nutrition supplementation timed to rainy seasons, swim-safety modules linked to community early-warning systems, and referral to school-based climate-resilient agriculture clubs. Vietnam’s MDA-plus-nutrition model already demonstrates 90+% coverage; layering climate indicators adds negligible cost (USD 0.20–0.40 per child) yet multiplies ROI.

Decennial certifications further enable adaptive surveillance. Age-20, 30 and 40 reviews can track shifting disease ecology, feeding real-time data into national climate-health adaptation plans. Countries adopting the Decade Dividend thus gain a dual dividend: healthier children today and measurable progress on SDG 13 tomorrow. Pilot districts in flood-prone Bangladesh or drought-affected Ethiopia could generate the first “climate-adjusted human-capital” dashboards within 24 months.

Bridging to Prevention

The Decade Dividend breaks the causal chain from early health disparities to lifelong economic stagnation. Targeted health checks at age 10 represent a strategic inflection point. They identify chronic risk early. They integrate reliable data into national planning systems. Public health shifts from managing deficits to compounding prevention returns. All digital elements remain strictly compliant with national data-protection frameworks.

Alternative Approaches and Limitations

Annual well-child visits (ages 0–18) incur higher lifetime costs (USD 50–100 per child) with documented participation fatigue beyond early childhood. Digital-only screening excludes 30–40% of populations in rural LMICs without reliable connectivity (GSMA, 2024). Reactive case-finding misses 60–70% of asymptomatic NTD carriers (WHO, 2025b). The Decade Dividend offers targeted, census-aligned efficiency at approximately USD 12 per child while generating population-level health metrics absent in alternative models.

3.  Benefits of Age-10 Health Checks

Age 10 marks optimal intervention when 70-80% chronic risk solidifies but behaviours remain malleable. The Global Action for Measurement of Adolescent health (GAMA) provides 47 indicators across 6 domains (health determinants, outcomes, systems performance, behaviours, well-being, policy) for standardized adolescent screening worldwide.  GAMA’s core indicators validate the Decade Dividend protocol.

Domain	Core Indicator	Decade Dividend Link
Health Determinants	Food Insecurity (FIES)	Stunting risk tracking
Health Outcomes	Anaemia Prevalence	NTD/iron deficiency marker
Systems Performance	Preventive Health Access	Decennial participation rate

Table 1: The Decade Dividend embraces additional GAMA indicators where local circumstances prove responsive

Why Age 10: Window of Opportunity

The Decade Dividend framework positions age 10 as a pivotal point for preventive health investment. It captures late childhood when physical growth accelerates in this preadolescent phase. Early vulnerabilities solidify while behaviours remain responsive to structured guidance through schools and community programmes. Stunting from early malnutrition stabilises into measurable deficits at this stage. Neglected tropical diseases (NTDs) begin causing subtle organ or cognitive damage. Developmental effects of early injury, including near-drowning, become clinically identifiable. Research indicates that approximately 70–80% of adult chronic-disease risk traces to patterns originating before puberty (World Health Organization [WHO], 2025a).

Universal checks one to two years before national censuses add systemic value. Age-10 health data underpins census data with verified and timely health metrics on nutrition, disease prevalence, and development. This produces health-adjusted population metrics that combine demographic surveillance with verified baseline health indicators. Brazil links early health screenings to census processes, strengthening Sustainable Development Goal (SDG) tracking. Policymakers gain genuine human-capital baselines rather than crude demographics.

Core Screening: Nutrition and Development

Comprehensive screening at age 10 interrupts progression from childhood risk to adult disease. School-based assessments incorporate anthropometric measurement (height-for-age, body mass index [BMI]). They include micronutrient testing for iron, vitamin A, and iodine. Brief cognitive and physical development checks follow. Nutrition counselling, dietary enrichment, or supplement programmes address findings. These normalize growth trajectories and reduce later diabetes incidence by approximately 20–30%, per cohort evidence from Guatemala and Brazil (Victora et al., 2008).

Developmental evaluations cover vision, hearing, motor coordination, and short cognitive tasks. Protocols could also adopt dyslexia screening, a vastly underacknowledged issue across LMICs despite affecting 10-15% of children, to expand benefits beyond physical health.  Mild anaemia affects about 40% of school-aged children worldwide. Detection yields immediate educational payoffs through improved attention and learning outcomes. A standardized 30-minute protocol delivers these interventions, averting premature cardiovascular disease, conserving cognitive capacity, and lowering adult healthcare expenditure.

Early Detection of Neglected Tropical Diseases

Targeted screening at age 10 yields efficient returns on early NTD detection in endemic regions. Simple stool, urine, or serological tests help identify soil-transmitted helminths and schistosomiasis before chronic anaemia or organ scarring. Low-cost antiparasitic regimens can help prevent problems in up to 90% of cases (World Health Organization [WHO], 2025b).

The Guinea-Worm Eradication Program illustrates surveillance power. Proactive detection and containment reduced global incidence by over 99% since 1986, eliminating a once-endemic disability source. Age-10 screening averts as much as 20–30% of long-term productivity loss from persistent parasitic infections (Centers for Disease Control and Prevention [CDC], 2024). Per-capita testing costs stay below USD 1. The fiscal rationale compels NTD diagnostic integration into universal child checks.

Basic blood-pressure readings, lipid profiles, and brief mental-health questionnaires can also help address chronic-disease precursors in the same appointment. Elevated blood pressure or cholesterol in late childhood correlates with adult cardiovascular disease. School-based behavioural programmes mitigate this, cutting later prevalence by 25–40% (Cohen et al., 2022). The Strengths and Difficulties Questionnaire (SDQ) identifies anxiety, attention deficit hyperactivity disorder (ADHD), or learning disorders, reducing school dropouts and protecting long-term earnings.

Drowning Risk and Environmental Safety

Drowning-risk assessment embeds within the broader screening protocol, extending prevention-based health development practice into environmental domains, particularly those amplified by climate-driven flooding. Questionnaires cover swimming ability, household proximity to water hazards, recent exposure history, and seasonal flood zone residency. These flag at-risk children for safety programme referral. Targeted interventions prevent injuries leading to lifelong cognitive or motor impairment, including swimming lessons, community barriers, and parental education.

Bangladesh’s national drowning surveillance program linked health data with environmental mapping. Coordinated agency responses documented a 40% reduction in childhood drowning (Lancet Commission on Drowning, 2024). Cambodia’s 2025 National Drowning Prevention Plan builds on grassroots community health development practice (Hile Teuk Kampuchea) and crafts a proactive model of government–non-governmental organisation (NGO) collaboration. The Age-10 protocol incorporates and institutionalises proven methods by embedding safety monitoring into national public-health policy.

Proven Models and Projected Impact

Germany’s U10 Untersuchung screens all 10-year-olds for growth, sensory, and chronic-disease risks. It identifies early hypertension or developmental delay in approximately 20% more children than later adolescent visits (Robert Koch Institute, 2023). Finland’s comprehensive school-child health system spans ages 7–11, combining physical and psychological assessments. Follow-up cohorts show a 25% reduction in adult cardiovascular markers.

National scaling implies 20–30% reductions in chronic-disease morbidity. Economic returns reach USD 7–13 per dollar invested through lower hospitalisation and sustained workforce participation (García et al., 2016; Gómez-Cotilla et al., 2024). Census-cycle synchronisation enhances precision policy planning, which yields verified health-adjusted population metrics. Implementation strictly conforms to national consent and data-protection frameworks, ensuring equitable, ethical use of personal information with independent ethics board oversight.

The Decade Dividend lens frames universal age-10 health checks as transition from reactive treatment to proactive prevention. This creates a unified platform where education, epidemiology, economics, and climate adaptation converge to generate long-term societal returns.

From Ad hoc Screening to Lifelong Decennial Health Certification

Single screenings fade; decennial certifications sustain prevention gains across working lifetimes, compounding USD 7–13 returns per dollar invested.

The Decade Dividend framework uses age-10 assessments to initiate lifelong health development monitoring. Decennial health certifications follow every ten years across the life course. These routine check-ups transform one-time screenings into continuous feedback systems for individuals and public-health planners. Singular health checks lose momentum, NTD reinfections return, neurological sequelae progress unnoticed, lifestyle habits drift.

Planned periodic certification reverses this attrition, preserving early gains and updating baselines at predictable intervals. Longitudinal health-exam programmes report 17% reductions in all-cause mortality and adhering populations show lower chronic-disease accumulation (Saito & Kobayashi, 2020). Each decennial review anchors individual behaviour to national data needs, normalising health prevention as a lifelong habit rather than a childhood episode.

Tracking Chronic Risks: NTDs and Post-Injury Sequelae

Regular certification underpins conditions requiring surveillance beyond childhood. In NTD-endemic regions, stool or serological testing occurs at ages 20, 30, and thereafter, detecting reinfection early. Prompt deworming or targeted imaging follows for chronic schistosomiasis survivors facing hepatic or bladder complications. Monitoring preserves 20–30% of lifetime productivity otherwise lost to recurrent anaemia or fatigue (World Health Organization [WHO], 2025b).

A comparable rationale applies to neurological sequelae of early drowning incidents. Follow-up screenings include cognitive evaluations and epilepsy assessments identifying residual hypoxic injury, reducing work capacity by 15–25% (World Health Organization [WHO], 2024). Periodic assessments link to community programmes, establishing continuity between paediatric prevention and adult care to sustain functional independence and national productivity.

Behavioural Reinforcement and Preventive Culture

Decennial certifications serve as timed behavioural prompts across adulthood. Each appointment triggers automated reminders for age-appropriate interventions, including immunisations, diet or exercise counselling, and climate-adaptive water-safety reviews. Delivery occurs through digital or community channels. Behavioural-science studies show recurring reminders double or triple adherence to preventive actions compared with one-off advice (García et al., 2016).

Integration with occupational and insurance frameworks magnifies impact. Premium discounts, tax benefits, or workplace wellness credits incentivise participation. Estonia’s national e-health system provides examples. These ties extend age-10 prevention culture, translating public-health goals into personal and economic incentives.

Digital Certification and Data Integration

Secure digital certificates form the operational backbone for monitoring. Encrypted records issue after each decennial assessment. These verified health identifiers provide access to individuals and authorised institutions. Transparent, privacy-protected platforms model Estonia, Singapore, and U.S. Medicare Wellness Visit approaches. Digital certification simplifies verification of vaccination, NTD clearance, and climate-sensitive risk profiles. Cross-sector data interoperability follows, with all digital sections strictly compliant with national data-protection frameworks.

Aggregated anonymised data feed national health dashboards. Policymakers map NTD recurrence, drowning outcomes, or shifting climate-disease patterns in real time. Singapore’s Health Hub shows digitised records reduce administrative costs by 30%; check-up participation rises to over 80% (Ministry of Health Singapore, 2024). U.S. Medicare AWVs demonstrate near-decennial follow-ups improve diabetes management markers (lower A1C, higher screening) across diverse groups (Kang et al., 2021; Marino et al., 2022).

Evidence and Projected Impact

Meta-analyses of periodic nationwide screening programmes show consistent decennial assessments improve health outcomes by 20–30% compared with single interventions (Saito & Kobayashi, 2020). Japan’s mandatory periodic-exam system records 22% lower cardiovascular mortality; regular participants see 17% reductions in overall deaths.

Economic modelling indicates USD 7–13 return per dollar invested in routine certifications. Benefits include reduced ambulance services and hospitalisation, lower disability costs, and longer labour-force participation (García et al., 2016; Gómez-Cotilla et al., 2024). Reviews integrate with age-10 data baselines, enabling governments to track generational health and productivity progress, including climate-adjusted human capital metrics. The Decade Dividend realises prevention compounding across decades, strengthening citizens, economies, and fiscal resilience.

4.  Productivity Gains from Prevention

The Decade Dividend framework combines age-10 health checks with lifelong decennial certifications, generating sustained productivity growth. A healthier population and longer-serving workforce result. Regular screenings mitigate chronic conditions such as cardiovascular disease (CVD) and diabetes. Participant cohorts see 20–30% reductions in incidence and 10–20% declines in absenteeism (Cohen et al., 2022; Saito & Kobayashi, 2020). Japan’s national health-exam programme recovers approximately 1.5 million workdays annually among adherent groups.

Healthier middle-aged populations extend active employment by 2–5 years, offsetting labour-force contraction from population ageing and decline. Nearly 2 billion individuals over 60 are expected globally by 2050 (United Nations, 2022). Preventive care maintains cognitive and physical vitality. Modelling shows sustained screening increases labour-force engagement by 5–10%, with productivity rising through reduced fatigue and improved concentration.

Containing Healthcare Expenditure Growth

Investment in prevention-based health development yields high fiscal returns. Early detection and lifestyle modification reduce dialysis, cardiac interventions, and the costs associated with long-term diabetes care. Meta-analyses estimate USD 7–13 per dollar invested, paralleling lifetime benefits from early-childhood programmes such as Perry Preschool Project (García et al., 2016; Gómez-Cotilla et al., 2024). Japanese participants in periodic health exams experience 25% fewer hospitalisations for metabolic and cardiovascular conditions (Saito & Kobayashi, 2020).

Chronic disease consumes an estimated 80% of health budgets in OECD countries. Prevention-based health development frameworks rebalance expenditure toward productive investment. Governments avert avoidable admissions, extending healthy years and redirecting funds to infrastructure, education, and wage growth.

Employment and Innovation Ecosystem

Universal decennial reviews stimulate economic development and employment across health and technology sectors. Expanded screening demands telehealth professionals, data analysts, and lifestyle counsellors. Projections indicate 5 million additional health-sector jobs in the United States and 10–15 million across Asia by 2030 (U.S. Bureau of Labor Statistics, 2023). Technological integration raises average wages and skills. New roles emerge in data science, artificial intelligence (AI) oversight, and ethics compliance.

AI amplifies efficiency. Automated analytics identify pre-diabetes or hypertension with up to 95% predictive accuracy; workflow administration streamlines by about 40%. Triage speed improves. High-skill oversight and algorithm-development roles increase. Care delivery shifts from low-wage reactive service to higher-wage innovation-driven employment.

Workforce Incentives and Scalability

Digital certification from decennial screenings enables performance-based incentives like insurance premium discounts (10–20%), employer tax credits, and preferential hiring, potentially raising participation to 85–90%.p4h+1

Singapore’s Healthier SG waives 15% co-payments for enrolled patients at enrolled clinics (from Feb 2024), driving over 700K enrolments and high digital uptake, a direct model for Cambodia’s incentives. Japan’s employer-linked mandates have similarly tripled screening compliance rates through enforcement and integration. Health Hub integration further shows chronic disease claims declining ~15% via preventive digital shifts (MOH Singapore).

Scalability provides a clear economic advantage. Digital infrastructure enables decennial updates at USD 5–10 per person. Aggregate productivity gains reach 1–2% of gross domestic product (GDP), per World Bank health-capital modelling, through extended healthy working years (Bloom et al., 2019). Prevention-based health systems achieve long-term fiscal sustainability, and employment quality improves.

National Economic Roadmap

Demographic ageing invariably presents economies with health and fiscal challenges. The Decade Dividend converts these into growth potential. Early childhood screening and periodic recertification avert USD 1–4 trillion annual global productivity loss from chronic disease and undernutrition (Bloom et al., 2019; United Nations, 2022). A 1–2% annual GDP advantage compounds national income across decades through three implementation stages:

• Pilot integration using existing census and school-health infrastructure
• Digital scale-up through secure national health registries
• Employment incentives via tax or insurance frameworks

This sequence transforms prevention-based health systems into an economic engine. It anchors workforce resilience, innovation, and climate-adaptive health systems across the life course. All digital sections remain strictly compliant with national data-protection frameworks.

5.  Feasibility, Challenges, and Global Scalability

Vietnam’s 95% MDA coverage and Cambodia’s drowning prevention strategy illustrate how age-10 screening integrates with existing infrastructure, delivering 90% reach at USD 0.62 per child.

Leveraging Existing Infrastructure

The Decade Dividend leverages existing delivery platforms. Vietnam integrates age-10 screening into NTD mass drug administration (MDA) programmes; Cambodia layers it onto national drowning prevention frameworks (in partnership with organisations like TLK). Coverage reaches 90% at USD 0.62–0.66 per child (World Health Organization [WHO], 2025b; Satrija et al., 2024). Initiatives layer nutritional assessments and basic developmental screening onto established logistics. Schistosomiasis prevalence reduced from over 70% to under 1% since the 1990s (Stothard et al., 2006).

Decennial certifications transition to digital platforms. Year 1 training of 1,000 nurses couples with census data integration. National rollout costs approximately USD 5 million, a fraction of chronic disease treatment costs. Existing public health investments maximise returns.

Achieving Equity Across Income Settings

Equity demands targeted strategies for low and middle-income countries (LMICs). Using mobile screening units and non-governmental organisation (NGO) partnerships, helps the model reach the bottom 40% income quintile. Vietnam’s rural MDA delivered deworming to 95% coverage in remote areas at USD 0.50 per treatment (Attia et al., 2022). Layering gender-specific protocols and prioritising adolescent girls for anaemia/NTD screening addresses nutritional disparities, advancing SDG 5 alongside SDG 13.

SMS-based exemptions and community health-worker incentives, plus the initial deployment of 500 mobile clinics through UNICEF partnerships at USD 3 per child, closed access gaps.  In turn, the structural inequity converts to more linear like health gains across urban-rural and socioeconomic divides.

Proven Pilot Frameworks

Adolescent health platforms provide tested pathways. WHO’s Global Action for Measurement of Adolescent health (GAMA) and Zimbabwe’s Y-Check initiative achieved 80% uptake among adolescents via school-based screening (WHO, 2025).

Indicator	Result	Strategic Implication
Identified Issue	90%	High yield for screening
Linkage to Care	70.8%	Referral infrastructure
Cost/Participant	USD 47	National scaling benchmark

Table 2.  Zimbabwe Y-Check Outcomes (2022–2023)

Age-10 NTD and developmental modules can adapt these models, aligning with the WHO NTD Roadmap 2021–2030. Guinea worm eradication demonstrates 99% success through phased surveillance (WHO, 2021).

A 10-district pilot over 6 months costs USD 2 million, measuring participation rates, detection yield, and cost efficiency before national expansion. Vietnam’s MDA scaling provides precedent.

Addressing Implementation Barriers

Interventions align with Sustainable Development Goal (SDG) 3 (health), SDG 8 (employment through training), SDG 10 (inequality reduction), and SDG 13 (climate action). GFF support enables nationwide expansion by 2030.

Barrier	Solution	Precedent
Logistics	AI-driven scheduling reduces wait times 50 per cent	Vietnam MDA platforms
Privacy	Secure digital anonymisation with data-protection compliance	Estonia e-health
Participation	Local training + incentives raise uptake 30 per cent	Japan employer mandates
Funding	GFF catalytic financing bridges pilot-to-scale	NTD control programmes

Table 3: Implementation Barriers

Counterarguments to General Health Checks

While general periodic screening shows mixed results for all-cause mortality in high-income adult populations (Krogsbøll et al., 2019), Decade Dividend differentiates by:

• Targeting LMIC developmental windows without incidental primary care
• Addressing irreversible middle-childhood biological programming (stunting/NTDs)
• Creating longitudinal accountability via decennial risk tracking

Cochrane excluded children/adolescents; age-10 preserves 40% adult productivity lost to chronic infection.

Implementation Roadmap

The Decade Dividend progresses through three phases:

• Year 1: Pilot integration – 10 districts using census/school infrastructure (USD 7 million total)
• Year 2–3: Digital scale-up – national telehealth platform, 500 mobile units (USD 25 million)
• Year 4+: Universal certification – digital certificates with employer incentives (USD 5–10 per person/decade)

This sequence leverages infrastructure, achieves equity through partnerships, validates via pilots, and generates climate-adjusted human capital data. Global health challenges convert to sustainable national assets. Implementation strictly complies with national data-protection frameworks, independent ethics board oversight, and explicit national consent protocols.

6.  Call to Action

USD 500M G20 fund + 10-district pilots within 18 months positions the Decade Dividend for WHA 2026 adoption.

The Strategic Imperative

The Decade Dividend framework offers governments, multilateral institutions, and civil society a pathway to convert childhood health inequality into national economic strength. Global health spending exceeds USD 10 trillion annually (World Health Organization [WHO], 2024). Paralysis forfeits generational prosperity. These include over 300,000 child drownings and 1.495 billion people requiring interventions against neglected tropical diseases (NTDs), both largely preventable (World Health Organization [WHO], 2024, 2025b).

Implementation costs approximately USD 12 per child for age-10 screening and decennial certification, per WHO GFF benchmarks (2024). This safeguards 10 million productive futures through reduced chronic morbidity and preserved human capital (World Bank, 2023). Vietnam’s NTD control programmes demonstrate how feasibility, integrated screening and treatment reduced schistosomiasis prevalence by over 70% (Satrija et al., 2024).

Vietnam Pilot Design (2027)

Objective: Deploy age-10 screening for 1 million students across 10 provinces

Protocol:

• Q1 2027: Train 5,000 enumerators (census staff)
• Q2-Q3: Screen via school census (Hb, helminths, growth, vision)
• Q4: Risk-stratify + family health book linkage

Targets:

• 85% participation rate
• 15% high-risk yield (anaemia/NTDs)
• $3/child total cost

Metrics:

Productivity impact modelling + national scale roadmap

Recommended Policy Actions

National and international authorities pursue coordinated steps:

• 2026 World Health Assembly (WHA) resolution: Integrates universal age-10 screening (NTDs, drowning risk, climate vulnerability) into WHO Essential Health Package with LMIC adaptation guidance
• National mandates in 50 LMICs by 2028: Launches school/clinic pilots via GFF catalytic grants, targeting 90% coverage using census infrastructure
• G20 multilateral commitment: Establishes USD 500 million pilot fund for digital health certification platforms with secure data-sharing protocols
• Public-private acceleration: Partners technology firms for AI triage/telehealth, replicating Singapore Health Hub (85% digital participation)

M&E Framework Table

KPI	Target	Data Source	SDG Link
Age-10 screening coverage	≥90%	School/census records, GAMA	SDG 3.2
NTD positivity reduction	30–50%	Stool/urine/serology tests	SDG 3.3
Stunting reversal (anthropometry)	≥20%	Height-for-age measurements	SDG 2.2
Drowning-risk referrals	≥80%	Screening questionnaires	SDG 3.9
Decennial participation rate	≥75%	Digital health certificates	SDG 3.8
Cost per DALY averted	<USD 150	WHO-CHOICE benchmarks	SDG 3.b
Climate-vulnerability flagging	≥85% accuracy	Environmental risk surveys	SDG 13.2

Table 4: Decade Dividend M&E Framework

Projected Returns and Urgency

Economic modelling suggests comprehensive adoption generates 1–2 percentage points of additional annual GDP growth (Bloom et al., 2019). Extended healthy working years and reduced chronic disease burden drive these gains. Post-pandemic global health priorities and the 2025 NTD Roadmap create optimal timing.

Delay perpetuates avoidable mortality and economic loss. Immediate trailblazing pilots in 10 high-burden districts worldwide could validate the framework within 18 months, aligning with the 79th World Health Assembly (May 2026). Independent ethics-board oversight and annual third-party audits ensure transparency.

The Decade Dividend transforms childhood health investment into a strategic national asset. Returns compound across generations and shifting climate horizons.

7.  Reference List

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García, J. L., Heckman, J. J., Leaf, D. E., & Prados, M. J. (2016). The life-cycle benefits of an influential early childhood program (NBER Working Paper No. 22993). National Bureau of Economic Research. https://doi.org/10.3386/w22993

Grantham-McGregor, S., et al. (2007). Developmental potential in the first 5 years for children in developing countries. The Lancet, 369(9535), 60–70. https://doi.org/10.1016/S0140-6736(07)60032-4

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Hile Teuk Kampuchea, HTK Partnership: https://hileteuk.org/

Intergovernmental Panel on Climate Change. (2023). Climate Change 2023: Synthesis Report. IPCC. https://doi.org/10.59327/IPCC/AR6-9789291691647

Kang MJ, et al. The Association Between Medicare Annual Wellness Visits and Detection and Management of Diabetes Among Older Adults. J Gen Intern Med. 2021.pmc.ncbi.nlm.nih​

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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

Brown meagre (Sciaena umbra)

News Flash 657

Weekly Snapshot of Public Health Challenges

 

Happiness is a Policy Choice: On LGBTQIA+ Well-Being and the Limits of Governance in India

IFIC Meeting registration: Family Carers Ireland & Integrated Care: Working Together for Better Support Mar 24, 2026

HRR809. ONCE UPON A TIME THERE WAS THE LEFT. (Louis Casado)

Progress in reducing child deaths slows as 4.9 million children die before age five

Letters from the Future: Call for Submissions

Inside CSW: What is at stake for gender equality?

Two truths and a lie: women are gaining, and losing in 2026

The Hidden Costs of Ignoring Gender

When gender equity NGOs close, more disappears than can be measured

Experts Warn of Rising Teenage Pregnancy Risks in Rwanda

Prevalence and Factors Associated with Abortion-related Health Risks among Female Sex Workers in Kyotera District, Uganda  by Ssemakula Micheal, Chris Byaruhanga

Essential standards for perinatal care of women and children living in prison

Improving neonatal outcomes through better access to human milk

South Africa: Activists Say SA’s Menstrual Product Regulation Is Not Transparent Enough, Despite Government Reassurance

Independent Directors as Catalysts of Transformation in the Healthcare Industry  by Tanushree Mondal 

Open letter: The Critical Medicines Act must deliver equitable, affordable access to medicines for all

New PRIME tools to accelerate development of medicines in the EU

One Billion Tests: Turning India’s Diagnostic Boom into Public Health Intelligence

Stop TB Partnership launches the InnoScan!

WHO targets new antibiotics to fight hospital ‘superbugs’

US Judge Halts RFK’s Anti-Vaccine Efforts – For Now

The shot that could stop cancer before it begins – and why getting it early matters

After a Decade of Progress Against HIV, PrEP Enters a Precarious Era

180 000 infections in 2024, 47 000 by 2045 — if SA rolls out the twice-a-year HIV prevention jab fast enough

Dengue observatory eyes global disease surveillance

Why sleeping sickness pill is raising hopes in Africa

War in the Middle East will impact neglected disease R&D globally

Deepening Middle East Conflict Displaces Millions; Threatens Water and Air Quality

Europe moots ‘more transactional’ climate outreach ahead of COP31

 

 

 

 

 

 

 

IN A NUTSHELL
Author's Note 
By strengthening ethical governance, promoting patient-centric accountability, overseeing digital transformation, ensuring regulatory compliance, and encouraging sustainable growth, Independent Directors can profoundly influence the future of the healthcare sector. Ultimately, effective healthcare governance is not just about corporate performance—it is about protecting human lives and building systems that deliver trust, transparency, and resilience. Independent Directors, when empowered to perform their roles effectively, can become one of the most important drivers of progress in the healthcare industry in the decades ahead

By Professor (Dr) Tanushree Mondal 

Editor – APCRI  Journal

Professor of Community Medicine, RG Kar Medical College, Kolkata, India

profcmrgkmc24@gmail.com

Independent Directors as Catalysts of Transformation in the Healthcare Industry

 

Governance at the Heart of Healthcare

Healthcare is not merely an economic sector; it is a critical pillar of social stability and human well-being. Hospitals, pharmaceutical companies, diagnostic networks, insurers, and health technology platforms collectively shape how societies prevent, diagnose, and treat disease. As healthcare systems grow more complex—driven by technological innovation, regulatory oversight, and rising patient expectations—the need for strong governance has never been greater. In today’s world, where governance is the keystone to every industry, this article opens our eyes to the broad trajectory.

In this evolving landscape, Independent Directors have emerged as key guardians of accountability, ethics, and long-term strategic thinking. Their role extends beyond regulatory compliance to ensuring that healthcare organisations balance financial sustainability with patient-centric outcomes and satisfaction scores.

In countries all around the globe, where healthcare demand is expanding rapidly and regulatory frameworks are becoming more sophisticated, Independent Directors can play a transformative role in strengthening governance, improving transparency, and building public trust. Institutions such as the Insurance Regulatory and Development Authority of India and the National Health Authority are advancing policy frameworks, but corporate boards ultimately determine how those frameworks translate into real-world outcomes. Moreover, Health Tourism has added a new dimension that needs governance attention.

The Changing Landscape of the Healthcare Industry

Healthcare today faces a unique convergence of challenges and opportunities:

• Rising healthcare costs globally
• Rapid technological transformation through AI, telemedicine, and digital health
• Increased regulatory oversight
• Growing patient awareness and demand for transparency
• Ethical concerns related to data privacy, clinical trials, and pharmaceutical pricing.

However, rapid expansion also introduces governance risks: opaque pricing, misaligned incentives, clinical ethics concerns, and operational inefficiencies. Independent Directors can help organizations navigate these complexities by bringing objective oversight and strategic discipline.

Why Independent Directors Matter in Healthcare Governance

Independent Directors are uniquely positioned to bring neutral judgment, diverse expertise, and stakeholder-focused oversight to healthcare boards.

Unlike executive directors or promoters, Independent Directors do not participate in day-to-day management. Their independence allows them to challenge decisions, question assumptions, and ensure that management actions align with long-term institutional goals.

In healthcare organizations, their presence is particularly important because the industry operates at the intersection of profit, regulation, and public welfare.

Their contributions can broadly be grouped into five key areas.

1. Strengthening Ethical Governance

Healthcare decisions often involve complex ethical considerations. These include patient consent, clinical trial transparency, pharmaceutical pricing, and equitable access to treatments. Independent Directors can help ensure that organizations maintain strong ethical standards by establishing robust governance frameworks. For instance, they can advocate for the formation of ethics committees, clinical governance boards, and transparent reporting systems. In recent times, few clinical trials have been found to occur not according the regulatory framework norms as these are funded by Giant Houses around the globe, and the sufferers are the poor and the merciless who are the target points for such heinous experiments.

In pharmaceutical companies, Independent Directors play a critical role in overseeing clinical trial governance. They can ensure that research protocols comply with international ethical standards and protect patient rights.

Ethical governance not only safeguards patient welfare but also protects organizations from reputational and legal risks.

2. Enhancing Patient-Centric Accountability

Traditionally, healthcare governance focused heavily on financial performance and operational efficiency. However, modern healthcare organizations are increasingly evaluated based on patient outcomes, service quality, and transparency.

Independent Directors can encourage boards to adopt metrics that measure patient-centric performance. These may include:

• Treatment outcomes and recovery rates
• Patient satisfaction scores
• Grievance redressal timelines
• Transparency in pricing and billing

By integrating such metrics into board-level reporting systems, Independent Directors ensure that patient welfare becomes a core strategic priority.

3. Oversight of Digital Health Transformation

The healthcare industry is undergoing a digital revolution. Technologies such as artificial intelligence, electronic health records, telemedicine, and predictive analytics are reshaping healthcare delivery.

While these innovations offer tremendous opportunities, they also introduce governance challenges related to data privacy, cybersecurity, and algorithmic bias.

Independent Directors must ensure that digital transformation initiatives are implemented responsibly. Boards should establish clear policies regarding patient data protection, technology vendor oversight, and ethical AI usage.

In an era where healthcare data is becoming one of the most valuable digital assets, governance oversight is essential to prevent misuse and maintain patient trust.

4. Strengthening Risk Management and Regulatory Compliance

Healthcare is one of the most heavily regulated industries in the world. Compliance requirements span areas such as clinical standards, drug approvals, insurance regulations, and hospital accreditation.

Independent Directors play a vital role in ensuring that healthcare organisations maintain robust risk management frameworks. They can oversee compliance structures, audit processes, and internal controls to ensure adherence to regulatory requirements. In this era, physicians must not restrict them to medical advances and medical literature, but at the same time, must combine the art and science of corporate and clinical governance too, admixed with Enterprise Risk Management, CSR projects and so on and so forth.

For example, health insurance companies operating under the supervision of the Insurance Regulatory and Development Authority of India must follow strict guidelines regarding policyholder protection and claim settlement practices.

Independent Directors can ensure that compliance is not treated merely as a legal obligation but as an integral part of corporate governance.

5. Encouraging Long-Term Strategic Thinking

Healthcare investments often involve long development cycles and significant capital expenditure. Pharmaceutical research, hospital infrastructure, and digital health platforms require long-term commitment.

Management teams may sometimes face pressure to deliver short-term financial results. Independent Directors help balance these pressures by advocating for strategies that prioritize sustainable growth and long-term value creation.

For instance, Independent Directors may encourage investments in preventive healthcare, community health programs, or digital health infrastructure—initiatives that may not yield immediate profits but generate long-term societal and economic benefits. 

Independent Directors and Healthcare Innovation

Innovation is essential for addressing modern healthcare challenges such as aging populations, emerging diseases, and rising treatment costs.

Independent Directors can foster innovation by encouraging collaboration between healthcare organizations, technology companies, academic institutions, and research laboratories. They help to gel various industry knowledge and practices together.

They can also ensure that innovation initiatives align with ethical standards and regulatory requirements.

In pharmaceutical companies, Independent Directors may oversee R&D governance and ensure that research investments are strategically aligned with global health priorities.

Building Public Trust Through Transparent Governance

Trust is the cornerstone of the healthcare sector. Patients must trust doctors, hospitals, pharmaceutical companies, and insurers with their health and personal data.

When governance failures occur—such as unethical clinical practices or opaque pricing—they can erode public confidence in the entire healthcare ecosystem.

Independent Directors serve as custodians of transparency. By ensuring that organizations maintain clear communication, responsible marketing practices, and fair pricing policies, they help strengthen public trust.

Transparency in governance also improves relationships with regulators, investors, and patients.

The Role of Independent Directors in Health Insurance

Health insurance companies play a crucial role in financing healthcare systems. They influence access to medical services, pricing structures, and patient affordability.

Independent Directors in insurance companies can ensure fairness in claim settlement processes, transparency in policy design, and ethical underwriting practices.

By monitoring metrics such as claim settlement ratios, grievance resolution timelines, and policyholder satisfaction, Independent Directors can ensure that insurers maintain a customer-centric approach.

This governance oversight ultimately enhances the credibility of the insurance ecosystem.

The Future of Board Governance in Healthcare

As healthcare systems become more interconnected and technology-driven, the responsibilities of Independent Directors will continue to expand.

Future healthcare boards are likely to require directors with expertise in:

• Digital health and Artificial Intelligence
• Public health policy
• Healthcare economics
• Data governance and Cybersecurity

Independent Directors with multidisciplinary knowledge will be essential for guiding healthcare organizations through the next phase of industry transformation.

Conclusion

Independent Directors as Guardians of Healthcare Integrity. The healthcare industry stands at a critical crossroads. Rapid technological innovation, expanding patient expectations, and increasing regulatory scrutiny are reshaping how healthcare organizations operate. In this complex environment, Independent Directors serve as guardians of integrity, accountability, and long-term strategic vision. By strengthening ethical governance, promoting patient-centric accountability, overseeing digital transformation, ensuring regulatory compliance, and encouraging sustainable growth, Independent Directors can profoundly influence the future of the healthcare sector. Ultimately, effective healthcare governance is not just about corporate performance—it is about protecting human lives and building systems that deliver trust, transparency, and resilience. Independent Directors, when empowered to perform their roles effectively, can become one of the most important drivers of progress in the healthcare industry in the decades ahead.

 

IN A NUTSHELL
Authors' Note

Background: Unsafe abortion is a leading cause of maternal morbidity and mortality, particularly among vulnerable populations such as female sex workers (FCSWs). In Uganda, little is known about the prevalence and determinants of abortion-related health risks in this population, especially in rural districts like Kyotera. This study aimed to assess the factors associated with abortion-related health risks among FCSWs in Kyotera District, Uganda.

Methods: A cross-sectional study was conducted among 152 FSWs in Kyotera District. Participants were recruited using purposive and snowball sampling. Data were collected via structured questionnaires and key informant interviews. Quantitative data were analyzed using SPSS v26 with descriptive statistics and logistic regression to identify factors associated with abortion-related health risks. Qualitative data were analyzed thematically to supplement quantitative findings.

Results: Overall, 49% experienced abortion-related health risks and nearly half (48.7%) of participants reported a history of abortion, with 37% experiencing complications and 70.3% undergoing unsafe procedures. Significant predictors of abortion-related health risks included awareness of safe abortion services (Exp(B)=0.29, 95% CI: 0.11-0.79, p=0.018), access to post-abortion care, (Exp(B)=0.40, 95% CI: 0.18-0.89, p=0.026), and satisfaction with SRHS (Exp(B)=0.32, 95% CI: 0.13-0.79, p=0.013).

Conclusion: FCSWs in Kyotera District face a high burden of abortion-related health risks. Targeted interventions addressing SRHS (sexual and reproductive health services) access, stigma, and healthcare provider attitudes are crucial to reducing abortion-related complications.

Link to the original dissertation HERE 

By Ssemakula Michael¹, Chris Byaruhanga²

¹MPH Candidate, Uganda Martyrs University, Uganda

²Lecturer, Faculty of Health Sciences, Department of Public Health, Kampala University, Kampala, Uganda

Corresponding author: Ssemakula Micheal, Email: michaelssemakula5@email.com; Phone: +256-781415037

Prevalence and Factors Associated with Abortion-related Health Risks among Female Sex Workers in Kyotera District, Uganda

 

Background

Unsafe abortion remains a significant and largely preventable public health challenge, particularly in low- and middle-income countries (LMICs) where legal, social, and economic barriers limit access to safe reproductive healthcare(Ishola et al., 2021; Onuoha et al., 2025). Globally, half of all pregnancies are unintended (UNFPA, 2022), 6 out of 10 unintended pregnancies end in induced abortion and an estimated about 45% of abortions occurring annually  are unsafe abortion and this is viewed to be the cause of 7% of maternal fatalities. And some study revealed that about 77% of the 6.2 million unsafe abortions that happened each year are done in unsafe circumstances, leading to serious health issues and high financial and social expenses. The issue is made worse by legal limitations and restricted access to safe abortion services (Adeyemi, 2025; WHO, 2025a). It should come as no surprise that the majority of female sex workers use herbs, soap, and other drugs like cannabis, cocaine, and amphetamine-type stimulants to induce abortions, which are unhealthy and have claimed the lives of numerous women in Sub-Saharan Africa (Batham & Barry, 2024).

In 2010, the government of Uganda banned the operations of TBAs (traditional birth attendants) with an intention of reducing the high maternal mortality rates because while TBAs have community trust and local knowledge, they lack formal medical training to handle complications during birth, leading to negative health outcomes like birth asphyxia and fistula,  many women in sexual transaction still get assistance during giving birth for fear of social stigma and costly medical assistance, thus some over bleed after giving birth while others fail to deliver, thus endangering their lives(Abdulla et al., 2024; Kyeyune, 2020; Razu et al., 2025).

A recent study revealed that In Uganda, approximately 65% of births are attended by a skilled birth attendant, which includes medical nurses and midwives. Others showed that 15% of deliveries still occur in villages, often without skilled healthcare providers. In such rural areas, access to maternal health services remains limited, with women relying on traditional birth attendants or neighbors. This poses a significant challenge in managing emergencies, especially for those experiencing complications(WHO, 2025b).This statistic highlights the significant role of medical nurses in assisting women during childbirth, contributing to improved maternal health outcomes(WHO, 2025b).

These statistics highlight the vulnerability of women of reproductive age to unintended pregnancies, inadequate contraceptive coverage, and limited access to comprehensive sexual and reproductive health services (SRHS)(Asrat et al., 2024; Kassie et al., 2025). Despite global efforts to reduce maternal mortality, unsafe abortion continues to undermine reproductive health outcomes, particularly among socially marginalized populations (Dias Amaral & Sakellariou, 2021; Hajji Adam & Daba, 2024; Onuoha et al., 2025).

In Uganda, restrictive abortion laws, sociocultural stigma, limited awareness of legal provisions, and health system inadequacies exacerbate the risks of unsafe abortion(Mungau et al., 2026; Safe2ChooseTeam, 2025; WWM, 2025).

While post-abortion care is legally permitted, many women delay or avoid seeking care due to fear of legal consequences, discrimination, or breach of confidentiality. These challenges disproportionately affect women with limited autonomy or constrained access to health services, reinforcing the hidden yet critical burden of unsafe abortion in the country(Christine et al., 2024; Muga et al., 2024).

Female sex workers (FSWs), constitute one of the most vulnerable groups in Uganda’s reproductive health landscape. The nature of sex work exposes FSWs to multiple sexual partners, inconsistent condom use, and elevated risks of sexually transmitted infections (STIs), including HIV (Abdulla et al., 2024; Maringwa et al., 2025; O’Brien et al., 2022; Razu et al., 2025). These occupational risks, combined with limited and inconsistent access to effective contraception, significantly increase the likelihood of unintended pregnancies. In contexts where abortion is highly restricted and stigmatized, unintended pregnancies among FSWs often result in unsafe abortion practices, heightening the risk of severe reproductive health complications (Rai et al., 202; Bosurgi et al., 2022; Iden, 2022; Al-Worafi, 2023; Adair et al., 2024).

Abortion-related health risks among FSWs are further shaped by social and structural determinants. Criminalization of sex work reinforces stigma and discrimination in healthcare settings, limiting timely access to reproductive health services(Shapiro & Duff, 2021;Khezri et al., 2023; Willis et al., 2023). Economic dependence on sex work, limited negotiating power with clients, poverty, and fear of exposure further constrain reproductive decision-making and service utilization(Cunningham & Shah, 2020; Gloss et al., 2025). Conceptually, these intersecting vulnerabilities create a syndemic environment in which unsafe abortion is both a consequence of structural inequities and a driver of poor health outcomes among FSWs(Hernandez Barrios et al., 2024; Hernández Barrios et al., 2022; Outram et al., 2024).

The public health consequences of unsafe abortion in this population are multifaceted. Clinically, unsafe abortion is associated with hemorrhage, infection, infertility, chronic pelvic pain, and maternal death. Psychosocially, it contributes to anxiety, depression, and post-traumatic stress, conditions often under-recognized in programs targeting marginalized women (Sedgh et al., 2016; Shah & Ahman, 2019). Economically, abortion-related complications impose burdens on families and overstretched health systems, particularly in rural districts with limited access to emergency obstetric care. These cumulative effects underscore unsafe abortion as both a medical and social health challenge.

Despite these risks, empirical evidence on abortion-related outcomes among FSWs in Uganda remains limited. Most research has focused on the general female population, often overlooking high-risk subgroups whose reproductive health needs are unique. Evidence from sub-Saharan Africa indicates that FSWs face distinct behavioral and structural barriers to SRHS, including stigma, discrimination, lack of confidentiality, and provider bias, which limit access to contraception, safe abortion information, and post-abortion care (Okal et al., 2016; Beyeza-Kashesya et al., 2020). Consequently, conventional maternal health programs may inadequately address their needs, highlighting the importance of context-specific research that integrates behavioral, social, and structural determinants of abortion-related risks.

Policy frameworks and maternal health interventions in Uganda have largely neglected marginalized populations such as FSWs. Conceptual frameworks in reproductive health posit that reproductive outcomes—including unsafe abortion—result from interactions between individual behaviors (e.g., contraceptive use), interpersonal dynamics (e.g., condom negotiation with clients), and structural factors (e.g., legal restrictions, healthcare accessibility). Applying this multilevel perspective allows for a comprehensive understanding of how proximal, intermediate, and distal determinants interact to influence abortion-related health risks.

At the district level, particularly in rural areas like Kyotera, data on abortion-related health risks among FSWs remain scarce. Kyotera is characterized by active sex work networks, high HIV prevalence, and limited access to specialized reproductive health services, creating a high-risk environment for unintended pregnancy and unsafe abortion. This lack of localized evidence undermines the development of targeted, evidence-based interventions and policies to protect this vulnerable population.

This study therefore aimed to determine the prevalence and factors associated with abortion-related health risks among female sex workers in Kyotera District, Uganda. It examined sociodemographic, behavioral, and structural determinants—including contraceptive use patterns, history of unintended pregnancy, economic vulnerability, and access to sex-worker-friendly reproductive health services—that influence abortion-related health outcomes.

Generating context-specific evidence is critical for guiding reproductive health programming, informing policy, and supporting interventions aimed at reducing preventable maternal morbidity and mortality among marginalized women, consistent with global efforts to promote reproductive rights and health equity.

The Health Belief Model (HBM) provides a framework for examining individual-level influences on reproductive health behaviors. According to HBM, engagement in health-promoting or risk behaviors is shaped by perceptions of susceptibility to adverse outcomes, the severity of these outcomes, perceived benefits of action, and perceived barriers, alongside cues to action and self-efficacy (Rosenstock, 1974)(Alyafei & Easton-Carr, 2025)(Khormi, 2025).

In the context of FSWs, decisions regarding abortion are influenced not only by awareness of the potential complications of unsafe abortion but also by barriers such as stigma, financial constraints, and fear of legal repercussions. Applying HBM in this context allows researchers and policymakers to identify critical points for intervention, such as enhancing knowledge, addressing misconceptions, and building self-efficacy, which can improve the uptake of safe abortion services and reduce health risks(Koiwa et al., 2024; Beumer & Reilingh, 2025).

Complementing this individual-level perspective, the Social Ecological Model (SEM) highlights the broader social and structural factors that shape reproductive health risks. SEM emphasizes that behaviors are influenced by multiple, interacting levels, including interpersonal relationships, community contexts, and societal structures (Bronfenbrenner, 1977; McLeroy et al., 1988)(: Campbell, 2025)(Guy-Evans, 2024)(Kilanowski, 2017). For FSWs, interpersonal factors such as client and peer relationships, community-level access to reproductive health services, and societal factors including restrictive abortion laws and criminalization of sex work collectively influence abortion-related health outcomes.

Incorporating SEM provides a framework for understanding how structural and contextual barriers intersect with individual perceptions, guiding the design of multi-level interventions that address legal, social, and health system constraints(Caperon et al., 2022). Together, HBM and SEM offer complementary applicability: while HBM informs strategies to modify individual behaviors and perceptions, SEM supports interventions targeting social and structural determinants, providing a comprehensive approach to reducing unsafe abortion and improving reproductive health among FSWs(Pan & Pan, 2020; Taflinger & Sattler, 2024)

Methods

Research design

This study employed a cross-sectional, mixed-methods design with an explanatory sequential approach to examine the prevalence and factors associated with abortion-related health risks among female sex workers (FSWs) in Kyotera District, Uganda. The study first collected quantitative data to measure prevalence and associations with individual, environmental, and healthcare-related factors, followed by qualitative data to explain and contextualize these findings. In-depth interviews, focus groups, and key informant interviews were all part of the qualitative component, which offered insights into the social, structural, and health-system elements impacting abortion practices. This method made it possible to gain a thorough grasp of how structural, behavioral, and social factors interact to influence the health risks associated with abortion.

Study area

The study was conducted in Kyotera Town Council and Kasali areas of Kyotera District, a rural district in Central South Uganda with an estimated population of 275,296, predominantly of the Baganda ethnic group.

Map of Ugandan districts with Kyotera highlighted in red. Credit Wikipedia

The district is characterized by low-income settlements, high poverty, limited access to healthcare, and a thriving sex work economy in lodges, bars, and informal settlements. These factors made Kyotera a suitable setting for investigating abortion-related health risks among marginalized women exposed to socioeconomic vulnerabilities and structural barriers to reproductive healthcare.

The study population comprised FCSWs aged 18–50 years who engaged in transactional sex in the study area, including both young women (18–24 years) and adults (25–50 years). Eligibility required residence in the study area and willingness to provide informed consent. Participants were excluded if they were unable to communicate in English or Luganda, had previously participated in a similar study, or were school-going students, ensuring the study focused on women whose reproductive health experiences were shaped by transactional sex in the community.

Sample size and sampling techniques

The quantitative sample size was calculated using Kish Leslie’s formula, based on a 95% confidence level, 5% margin of error, and an estimated 10% prevalence of unsafe abortion in Uganda. This yielded a sample of 138 participants, which was increased by 10% to account for non-response, resulting in 152 respondents. Participants were recruited from hotspots such as lodges, bars, and informal settlements, with peer leaders facilitating access.

For the qualitative component, purposive sampling identified twenty (20) participants for four focus group discussions and five (5) key informants, including healthcare workers and district health officials. This ensured rich and diverse insights into abortion practices, reproductive health access, and systemic challenges.

For the quantitative component, we used cluster, simple random sampling due to its potential to provide respondents that could give information for generalizability purposes.

Data collection methods

Data collection employed researcher-administered structured questionnaires for the quantitative component and semi-structured interview guides for qualitative data. Questionnaires captured sociodemographic characteristics, reproductive history, contraceptive use, abortion experiences, complications, and access to sexual and reproductive health services (SRHS). Tools were pretested among fifteen FCSWs in Nyendo Town to refine clarity, appropriateness, and reliability.

Focus group discussions and in-depth interviews explored personal experiences, social influences, and healthcare-seeking behaviors, while key informant interviews examined structural barriers to safe abortion services. All interviews were conducted in English or Luganda and audio-recorded with consent.

Variables

The dependent variable was the prevalence of exposure to abortion-related health risks, defined as a history of abortion and associated complications.  Independent variables included individual factors (age, education, marital status, duration in sex work, contraceptive use, history of unintended pregnancy), environmental factors (peer influence, economic dependence, social support, stigma), and healthcare-related factors (awareness, accessibility, and satisfaction with SRHS, availability of post-abortion care, and distance to facilities). Variables were selected based on previous research demonstrating their relevance to abortion outcomes among marginalized women.

Data management and analysis

Quantitative data were managed and analyzed using SPSS version 26. Data were screened, coded, and entered into the software. Univariate analysis described participant characteristics and abortion outcomes. Bivariate analysis using Chi-square tests and Pearson correlations assessed associations between independent variables and abortion-related health risks. Variables significant at p<0.05 were included in a multivariate binary logistic regression model to identify independent predictors. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported, with AOR>1 indicating increased risk and AOR<1 indicating protective associations.

Qualitative data were analyzed using content analysis, involving repeated reading of transcripts, coding, and categorization into themes and sub-themes. Themes captured individual experiences, social influences, and structural barriers related to abortion practices among FCSWs. Integration of quantitative and qualitative findings allowed triangulation, contextualizing statistical associations within lived experiences and enhancing interpretive depth.

Quality control measures

Quality control measures included review of research instruments by supervisors and the ethics committee, yielding a Content Validity Index (CVI) above 0.7. Reliability was assessed using test-retest procedures and Cronbach’s alpha, retaining only consistent items. Six trained research assistants, including midwives and nurses, supported data collection. All completed questionnaires were checked for completeness, coded, and securely stored. Questionnaires in English were interpreted into Luganda where necessary to improve comprehension and reduce reporting bias.

Ethical considerations

Ethical approval was obtained from the Uganda Martyrs University Research Ethics Committee (UMUREC), and administrative clearance was granted by local authorities. Written informed consent was obtained from all participants, who were assured of voluntary participation, confidentiality, and the right to withdraw at any time. Data were anonymized using serial numbers, and interviews were conducted in private settings to protect participants’ privacy.

Study Limitations and Mitigation Measures

This study had several limitations that should be acknowledged. First, the cross-sectional research design limited the ability to establish causal relationships between variables since data were collected at a single point in time. However, this limitation was mitigated by carefully interpreting the findings in relation to existing literature and using appropriate analytical procedures to ensure credible associations.

Second, the study relied on self-reported data, which may be affected by recall bias and social desirability bias, particularly because abortion is a sensitive topic. To reduce this risk, participants were assured of anonymity and confidentiality, interviews were conducted in private settings, and research assistants were trained to use neutral and non-judgmental questioning techniques to encourage honest responses.

Finally, the findings may have limited generalizability beyond the selected hotspots in Kyotera District. Nevertheless, the purposive focus on these hotspots allowed the study to capture experiences of populations most affected by abortion-related health risks, thereby providing valuable context-specific evidence for informing reproductive health policies and targeted interventions in similar rural settings.

Results

Participant Characteristics

A total of 152 female sex workers (FSWs) participated. Table 1 summarizes their sociodemographic characteristics.

Table 1: Sociodemographic Characteristics of Respondents (n = 152)

Variable	Category	Frequency	Percentage (%)
Age Bracket in years	18–30	86	56.6
	31–40	43	28.3
	41–50	23	15.1
Marital Status	Single	102	67.1
	Married	35	23.0
	Divorced/Separated	15	10
Education Level	None	18	12
	Primary	70	46
	Secondary	45	29
	Tertiary	19	13
Duration in Sex Work	<1 year	28	18
	1–5 years	92	61
	>5 years	32	21
Monthly Income (UGX)	<100,000	56	36
	100,000–300,000	68	45
	>300,000	28	19

Interpretation: The majority were young (18–30 years) and single (67.1%), with nearly half (46%) having primary education. Most earned <300,000 UGX/month, reflecting socioeconomic vulnerability. A majority (60.5%) had been in sex work for 1–5 years.

Prevalence of Abortion-Related Health Risks

Figure 1: A bar graph showing Prevalence of Specific Abortion-Related Health Risks in Kyotera District

The findings in Figure 1, indicate a notable prevalence of abortion and related health risks among the respondents. Nearly half (51%) of the participants reported no history of abortion. Among those who had experienced abortion, a considerable proportion reported experiencing complications, Specifically, the majority of participants (63%) reported no complications. Regarding the type of abortion among respondents who had previously terminated a pregnancy, most of the participants reported having undergone unsafe abortions (70%). This high proportion of unsafe procedures highlights the significant exposure of women in the study population to abortion-related health risks. The findings here demonstrate that unsafe abortion remains prevalent among the respondents and may contribute substantially to the occurrence of abortion-related complications within the study area.

Prevalence of Exposure to Abortion-Related Health Risks

Figure 2: Overall Prevalence of Exposure to Abortion-Related Health Risks among FSWs in Kyotera District

The study found that 49% of participants had a history of abortion, with 70% of these abortions being unsafe (34.3% of total participants). Among those who had an abortion, 37% reported complications (18.1% of total participants). Considering these risks, the overall prevalence of exposure to abortion-related health risks is approximately 49% (had abortion, many with risks), while 51% of participants are not exposed (no abortion history).

Healthcare System Factors

Table 2: Health Service Accessibility (n = 152)

Variable	Category	Frequency (n=152)	Percentage (%)
Awareness of safe abortion services	Aware	42	28
	Not aware	110	72
Access to post-abortion care	Accessed	58	38
	Didn’t access	94	62
Satisfaction with SRHS	Satisfied	46	31
	Not satisfied	106	69
Distance to facility	<5 km	74	49
	>5km	78	51

The results in table 2 revealed that the majority of the participants reported to be unaware about safe abortion services, 62% didn’t have easy access to post-abortion care, 69% were not satisfied with Sexual Reproductive Health Rights (SRHS), and half of the participants were above 5 km distant to the health facility.

Key Informant Interviews (KII) of 7 participants revealed that the female sex workers often arrive the health facility late while others don’t receive medical attention at the hospital thus resorting to alternative treatment.

“We try to integrate post-abortion care into SRHS, but sex workers often arrive late or use informal providers first, worsening complications.” (KII, DHO, Kyotera).

Individual Factors Associated with Abortion-Related Health Risks

Table 3: Bivariate Analysis of Sociodemographic Factors (n = 152). 

Variable	Category	Experienced Risks	No Risks	χ²	P-value
Age group years)	18-30	39(46%)	47 (54%)	6.12	0.047*
	31-40	21 (49%)	22(51%)
	41-50	15 (65%)	8 (35%)
Marital Status	Single	56 (55%)	46 (45%)	0.35	0.839
	Married	13 (37%)	22 63%)
	Divorced/Separated	9 (60%)	6 (40%)
Education Level	None	14 (78%)	4 (22%)	8.35	0.015*
	Primary	35 (50%)	35 (50%)
	Secondary	21 (47%)	24 (53%)
	Tertiary	6 (32%)	13 (68%)
Duration in Sex Work	<1 year	6 (21%)	22 (79%)	9.67	0.008*
	1-5 years	38 (41%)	54 (59%)
	5 years	12 (38%)	20 (62%)
Monthly Income (UGX)	<100,000	12 (21%)	44 (79%)	12.45	0.001*
	100,000-300,000	26 (38%)	42 (62%)
	300,000	18 (64%)	10 (36%)

The bivariate analysis revealed significant associations between abortion-related risks and several sociodemographic factors. Notably, age (χ²=6.12, p=0.047), education level (χ²=8.35, p=0.015), duration in sex work (χ²=9.67, p=0.008), and monthly income (χ²=12.45, p=0.001) were significantly associated with experiencing abortion-related risks. Specifically, younger women (18-30 years), those with no formal education, longer duration in sex work, and higher-income individuals (>300,000 UGX) were more likely to experience abortion-related risks.

Table 4: Bivariate analysis for health system-related factors

Variable	Category	Exposed (n=75)	Not Exposed (n=77)	x	P-value
Awareness about Abortion-related risks	Aware	18 (24%)	24 (31%)	4.01	0.045*
	Not aware	57 (76%)	53 (69%)
Access to post-abortion care	Accessed	22 (29%)	36 (47%)	4.83	0.028*
	Didn’t access	53 (71%)	41 (53%
Satisfaction with SRHS	Satisfied	16 (21	30 (39%)	6.32	0.012*
	Not satisfied	59 (79%)	47 (61%)
Distance to facility	<5 km	30 (40%)	44 (57%)	3.1	0.078
	>5km	45 (60%)	33 (43%)

The findings in the table above show that awareness about abortion-related health risks (p=0.045), access to post-abortion care (P-value=0.028) and Satisfaction with Sexual Reproductive Health Services (p-value= 0.012) were found significantly associated with exposure to abortion-related health risks in Kyotera Districts at 95% confidence level. Distance to the health facility was found not significant.

Table 5: Multivariate Analysis by binary logistic regression model

Variables	B	S.E.	Wald	Sig.	Exp(B)95%	CI for Exp(B)
Awareness (1=Aware)	-1.23	0.52	5.62	0.018*	0.29	0.11-0.79
Access to post-abortion care (1=Accessed)	-0.92	0.41	4.95	0.026*	0.40	0.18-0.89
Satisfaction with SRHS (1=Satisfied)	-1.15	0.46	6.13	0.013*	0.32	0.13-0.79
Age bracket (1=18-30)	0.75	0.38	3.92	0.048*	2.12	1.01-4.45
Education Level (1=None)	1.23	0.56	4.82	0.028*	3.42	1.14-10.27
Duration in Sex Work (1=<1 year)	-1.45	0.62	5.45	0.020*	0.23	0.07-0.78
Monthly Income (1=<100,000	-1.82	0.53	11.83	0.001*	0.16	0.06-0.45

The binary logistic regression analysis revealed significant predictors of exposure to abortion-related health risks among the study participants.

Predictors of Exposure to Abortion-Related Health Risks

The model explained 42% of the variance in exposure to abortion-related health risks (Nagelkerke R²=0.42) and correctly classified 75% of cases. The Hosmer-Lemeshow test indicated a good model fit (χ²=5.12, p=0.745). Participants who were aware of safe abortion services had lower odds of exposure to abortion-related health risks (Exp(B)=0.29, 95% CI: 0.11-0.79, p=0.018). Similarly, accessing post-abortion care (Exp(B)=0.40, 95% CI: 0.18-0.89, p=0.026) and satisfaction with SRHS (Exp(B)=0.32, 95% CI: 0.13-0.79, p=0.013) were associated with reduced odds of exposure.

In contrast, participants aged 18-30 years had higher odds of exposure (Exp(B)=2.12, 95% CI: 1.01-4.45, p=0.048). No formal education (Exp(B)=3.42, 95% CI: 1.14-10.27, p=0.028), shorter duration in sex work (Exp(B)=0.23, 95% CI: 0.07-0.78, p=0.020), and lower monthly income (Exp(B)=0.16, 95% CI: 0.06-0.45, p=0.001) were also significant predictors. 

Qualitative results

Fear Stigma and discrimination

During Focus Group Discussion (FGD), one of the participants revealed fear to go to clinics for medication which made them use alternative means, thus unsafe abortions.

“We fear going to clinics because nurses judge us or gossip about our work. Sometimes we use herbs or buy pills from unlicensed vendors.” (FGD, 18–30 years)

“The stigma around sex work prevents women from seeking care early, which leads to complications.” (KII, Health Worker, Kyotera)

Use of Contraceptives

“Many girls start sex work very young and don’t know about family planning. So pregnancies happen and they try to terminate them unsafely.” (IDI, 22 years)

Environmental and Social Factors

Environmental determinants included peer influence, economic dependence, and social stigma. Participants reported that peers who had abortions influenced their decisions, and poverty limited access to safe providers.

FGD Quote:

“Even if a clinic is near, most of us cannot go. People know you are a sex worker, and the nurses judge you.” (FGD, 25–30 years)

Discussion

This study reveals a high prevalence of abortion-related health risks among female sex workers (FSWs) in Kyotera District, Uganda, with 48.7% reporting a history of abortion, 37% experiencing complications, and 70.3% undergoing unsafe procedures. These findings are consistent with previous studies in Uganda and East Africa, which reported abortion prevalence rates ranging from 11% to 58% among FCSWs (Beyeza-Kashesya et al., 2020; Okal et al., 2022; Sedgh et al., 2022)

For instance, a recent study found that FCSWs in Eastern and Southern Africa face numerous barriers to accessing reproductive health services, including stigma, lack of referral networks, and poor healthcare provider attitudes (Okal et al., 2022). These barriers contribute to high rates of unintended pregnancies and unsafe abortions.

Compared to other studies, this research fills several gaps. Firstly, it provides a comprehensive analysis of predictors of abortion-related health risks, including awareness of safe abortion services, access to post-abortion care, and satisfaction with SRHS. This is in line with Mbonye et al. (2022), who reported similar findings in Uganda. Secondly, the study focuses on Kyotera District, providing insights into a rural district in Uganda, unlike most studies that have focused on urban areas like Kampala (Kizito et al., 2022; Ndagire et al., 2022).

However, some limitations remain. The cross-sectional design of the study limits causal inferences, and self-reported data may be subject to biases in reporting abortion history and experiences. Future research should explore interventions addressing stigma and healthcare access, effectiveness of integrated SRHS and HIV services, and experiences of FCSWs in rural areas.

The findings of this study have implications for policy and practice. There is a need for targeted interventions to improve access to safe abortion services and post-abortion care among FCSWs in Uganda.

Conclusion

This study highlights the high burden of abortion-related health risks among female sex workers (FSWs) in Kyotera District, Uganda (p<0.001). The findings underscore the need for targeted interventions to improve access to safe abortion services (Exp(B)=0.29, 95% CI: 0.11-0.79, p=0.018), post-abortion care (Exp(B)=0.40, 95% CI: 0.18-0.89, p=0.026), and SRHS (Exp(B)=0.32, 95% CI: 0.13-0.79, p=0.013). Integrating SRHS and HIV services, addressing stigma, and promoting non-judgmental healthcare provider attitudes are crucial steps towards reducing abortion-related complications among FSWs. Further research is needed to inform effective interventions and policy reform

Recommendations

Policy Recommendations

Develop and implement integrated service models addressing FSWs’ reproductive health and HIV needs and Provide training on non-judgmental, confidential services for FSWs.

Address stigma and discrimination by implementing policies and programs reducing stigma and promoting inclusive healthcare and improve access to safe abortion services.

Ensure availability of safe abortion services and post-abortion care in rural areas.

Programmatic Recommendations

Establish peer-led outreach programs enhancing awareness of SRHS and safe abortion options and SRHS and HIV service delivery should be strengthened, focusing on FSWs’ specific needs.

Future Research

1. Evaluate effectiveness of integrated SRHS and HIV services for FSWs.
2. Explore the FSWs’ experiences and barriers to accessing SRHS in rural Uganda.
3. Examine causal links between SRHS access and abortion-related health risks.

Authors’ Contributions

Ssemakula Micheal: Study design, data collection, analysis, manuscript drafting.
Ethics Approval and Consent to Participate

Chris Byaruhanga: Conceptualization, supervision, manuscript review, and interpretation of findings.

Ethical Approval

Ethical approval was granted by Mulago Hospital Research and Ethics Committee (MHREC). Written informed consent was obtained from all participants.

Competing Interests

The authors declare no competing interests.

References

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Beyeza-Kashesya, J., Kaharuza, F., & Mirembe, F. (2020). Contraceptive use among female sex workers in Uganda. BMC Women’s Health, 20, 241.

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Dias Amaral, M., & Sakellariou, D. (2021). Unsafe abortion and health inequities. Global Public Health, 16(10), 1550–1562.

Gloss, A., Mukasa, B., & Namukwaya, Z. (2025). Economic vulnerability among female sex workers in East Africa. Social Science & Medicine, 330, 115234.

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Physics and Ethics Converge in the Principle of Balance: From Quantum Stability to Sustainable Equity  by Juan Garay

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IN A NUTSHELL
Author's Note 
Modern physics reveals that the persistence of matter and the evolution of cosmic structure depend upon subtle, close-to-impossible finely calibrated balances among fundamental forces. Quantum stability prevents atomic collapse; cosmological expansion unfolds within narrow parametric conditions that allow galaxies and life to form and us observing the expansion of the universe from the opposite reality : matter. Humanity exists within a historically brief observational window in which the origins and dynamics of the universe remain empirically accessible. 

This paper argues that the structural principle underlying physical stability—dynamic equilibrium between opposing tendencies—offers a profound analogy for ethical systems. Drawing on Einstein, Planck, Hubble, Heisenberg, and Feynman, and relating these insights to the Sustainable Health Equity Movement (SHEM), we propose that sustainable equity represents the ethical analogue of physical balance. The convergence of physics and ethics around the principle of equilibrium suggests a unifying framework for planetary sustainability

By Juan Garay

Co-Chair of the Sustainable Health Equity Movement (SHEM)

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

Founder of Valyter Ecovillage (valyter.es)

By the same Author on PEAH: see HERE

Physics and Ethics Converge in the Principle of Balance

From Quantum Stability to Sustainable Equity

 

Introduction: A Universe Balanced on Thresholds

The 20th century transformed humanity’s understanding of reality. Through the work of Albert Einstein, spacetime became dynamic rather than static. Edwin Hubble demonstrated that galaxies recede from one another, revealing cosmic expansion. Max Planck introduced quantization, and Werner Heisenberg formalized the uncertainty principle. Richard Feynman later emphasized the astonishing fact that humans exist during a relatively small (considering the age of the universe from the big bang theory) narrow historical interval in which the universe is both structured and still observable in its origin signals.

These developments reveal a consistent pattern: physical existence depends not on excess, but on balance.

Quantum Stability: Why Matter Exists

Classical electrodynamics predicted atomic instability: an orbiting electron should radiate energy and collapse into the nucleus. The resolution emerged through quantum mechanics.

Planck’s quantization and Heisenberg’s uncertainty principle established that confinement of a particle within an arbitrarily small region implies increasing momentum and energy. Total collapse is therefore prohibited by quantum structure.

Atomic stability is not static equilibrium but quantized dynamic balance:

Excess localization → energy divergence.

Excess dispersion → absence of structure.

Matter persists within constrained freedom.

Cosmological Balance: Expansion, Gravity, and the Window of Observability

Einstein’s field equations describe gravity as curvature of spacetime. Hubble’s redshift observations revealed that space itself expands. Later detection of the cosmic microwave background confirmed an early hot dense phase.

Cosmic structure formation requires calibrated conditions:

If gravitational coupling were significantly stronger → premature recollapse.

If expansion were too rapid → no galaxy formation.

If dark energy dominated too early → no large-scale structure.

We inhabit a cosmological epoch uniquely suited for observational cosmology:

The cosmic microwave background remains detectable.

Galaxies beyond the Local Group are still observable.

Expansion history can be reconstructed.

In the far future, accelerated expansion will isolate gravitationally bound systems. Observers may perceive an apparently static local universe, lacking evidence of cosmic origin. Thus, humanity exists within a narrow epistemic window.

Feynman emphasized the extraordinary nature of this circumstance: we are conscious beings in a universe that is, for a limited time, intelligible.

Ethical Analogue: Sustainable Equity

The Sustainable Health Equity Movement (SHEM) advances a framework of sustainable equity grounded in planetary boundaries, distributive justice, and intergenerational responsibility.

At the societal level, analogous tensions exist:

Economic growth vs. ecological limits

Individual autonomy vs. collective welfare

Resource accumulation vs. equitable distribution

Excess consumption destabilizes ecological systems.

Excess concentration of wealth destabilizes social cohesion.

Excess restriction suppresses innovation and vitality.

Equity, in this framework, is not uniformity but dynamic balance within biophysical constraints.

Just as atomic stability requires constrained freedom, sustainable societies require bounded expansion.

From Physical Equilibrium to Ethical Responsibility

Physics does not prescribe morality. However, it reveals a structural truth: complex systems endure only within thresholds.

Human civilization now confronts planetary-scale instabilities—climate change, biodiversity loss, health inequities—that reflect departures from balance.

If physical systems collapse when parameters exceed stability domains, social systems are unlikely to behave differently.

The convergence of physics and ethics occurs at the recognition that sustainability requires calibrated equilibrium.

Love as Conscious Equilibrium

In physics, balance is automatic; in human systems, it is voluntary.

Love may be redefined—not sentimentally, but structurally—as the conscious maintenance of conditions that allow mutual flourishing.

Where physics enforces equilibrium through law, humanity must choose it through ethics.

Sustainable equity thus represents the ethical translation of a cosmological principle.

Conclusion

The microcosm persists through quantum balance.

The macrocosm evolves through gravitational and expansionary balance.

Human societies endure through ethical balance.

We live in a rare cosmological and civilizational window in which the consequences of imbalance are scientifically visible.

Physics and ethics converge in the principle of balance.

To ignore this convergence is to risk collapse.

To embrace it is to align human development with the structural logic of the universe itself.

 

References

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Feynman, R. P. (1965). The Character of Physical Law.

Sustainable Health Equity Movement (SHEM). Sustainable Equity Framework.

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A New World Order Where Might is Right

Not in My Name: Military Spending as Toxic GDP, Health Inequity, and the Case for Ethical Selective Tax Objection  by Juan Garay

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An ethical basis for research into health and climate change

 

 

 

 

 

 

 

IN A NUTSHELL
Author's Note 
As a follow up to my reflections on the Munich security conference, find an article here assessing the opportunity cost in human life/health inequity of the growing military spending. The article examines the moral implications of allocating a substantial share of global economic capacity to systems of violence while massive deficits in life‑assuring goods persist.

“Not in my name” becomes not only a moral protest against direct violence, but also a demand for fiscal priorities that safeguard life. Ethical selective tax objection emerges as a civic mechanism to articulate this demand

By Juan Garay

Co-Chair of the Sustainable Health Equity Movement (SHEM)

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

Founder of Valyter Ecovillage (valyter.es)

By the same Author on PEAH: see HERE

Not in My Name

Military Spending as Toxic GDP, Health Inequity, and the Case for Ethical Selective Tax Objection

 

Introduction

Global military expenditure in 2024 reached approximately USD 2.7 trillion, marking the largest annual allocation to organized capacity for violence in history.¹ Against a backdrop of persistent and profound structural deprivation, international security fora such as the Munich Security Conference 2026 have become platforms where Western powers articulate a worldview of escalating geopolitical tension and Western self-claimed supremacy and privilege. Recent analyses note that leading delegates at the Munich Security Conference framed the global order as undergoing “wrecking‑ball politics,” urging investment in hard power and asserting Western strategic supremacy amid rising multipolar tensions.⁶

This rhetoric of urgency, deterrence, and confrontation buttresses arguments for ever‑increasing military expenditure, even as fundamental questions about global justice and the allocation of scarce resources remain unresolved.

While direct conflict fatalities in 2024 are estimated at approximately 239,000 deaths,¹ a much larger and more persistent hazard to human life arises from structural inequity. In 2023, the net burden of health inequity (nBHiE) in deficit countries was estimated at 12.6 million avoidable deaths, out of 15.6 million globally.² These deaths occur in settings where basic conditions of health and dignity are chronically unmet due to resource distribution failures.

At the same time, the global deficit required to ensure a universal minimum dignity threshold is estimated at USD 7.563 trillion annually.² The present article examines the moral implications of allocating a substantial share of global economic capacity to systems of violence while massive deficits in life‑assuring goods persist.

Toxic GDP and Opportunity Cost

The concept of toxic GDP — portions of economic output that are used in ways that degrade human well‑being — provides an analytical lens for interpreting large‑scale military spending. As recent commentary on restoring the broken human deal argues, certain sectors of economic activity transform human work and wealth into social toxins when they sustain capacities for destruction rather than life support.³ Military expenditure exemplifies such toxic allocation.

When military spending of USD 2.7 trillion is compared to the USD 7.563 trillion required to close the global dignity deficit, the share of toxic GDP devoted to militarization is approximately:

2.7/7.563≈35.7%2.7 / 7.563 ≈ 35.7\%2.7/7.563≈35.7%

Applying this proportion to the 12.6 million excess deaths in deficit countries yields:

0.357×12,600,000≈4,498,2000.357 × 12,600,000 ≈ 4,498,2000.357×12,600,000≈4,498,200

Thus, ≈ 4.5 million preventable deaths annually can be ethically attributed to the opportunity cost of military expenditure. This estimate is not an epidemiological causation claim, but a proportional ethical attribution that highlights the moral significance of resource allocation choices.

Reframing Security as Health Justice

Security rhetoric at forums like Munich 2026, where Western leaders not only emphasize military readiness but also implicitly appeal to cultural and civilizational privilege to justify augmentation of defense budgets, necessitates reframing. The pursuit of deterrence and geopolitical advantage must be juxtaposed with the persistent neglect of structural deprivation that kills millions each year.

Public health and global justice frameworks argue that the prevention of avoidable death from inequity should be at least as central to national and global security policy as militarization.

Ethical Selective Tax Objection

From an ethical standpoint, citizens confronted with the moral asymmetry between militarization and life‑preserving investment may consider the legitimacy of ethical selective tax objection — a claim that taxpayers should not be compelled to finance expenditures that perpetuate structural harm when alternatives exist that directly save lives.

This idea is built upon traditions of conscientious objection to war taxation advocated by international civil society organizations such as Conscience and Peace Tax International and the National War Tax Resistance Coordinating Committee.⁵,⁶ An ethically informed model would allow taxpayers to redirect the proportion of their taxes corresponding to military expenditure toward funds dedicated to health equity, social protection, and basic dignity provision.

Such frameworks strengthen democratic accountability and foreground the moral agency of citizens in shaping public goods. They also align with broader movements in tax justice and human rights that seek to democratize fiscal policy and enhance transparency in how public revenues are deployed.

Conclusion

In 2024–2025, global military rhetoric—including that articulated at conferences such as Munich Security Conference 2026—is increasingly framed around Western strategic primacy, escalating geopolitical competition, and the necessity of higher defense spending.⁶ Despite this, proportional ethical analysis reveals that a large fraction of preventable mortality correlates with the opportunity cost of existing military expenditure relative to unmet basic human needs.

The projection that ≈ 4.5 million avoidable deaths per year can be proportionately attributed to these toxic allocations should give pause to policymakers and public health scholars alike. In an ethical world, defense (in US terms boldly called war) spending should shift to the protection of life through health equity and economic justice.

“Not in my name” becomes not only a moral protest against direct violence, but also a demand for fiscal priorities that safeguard life. Ethical selective tax objection emerges as a civic mechanism to articulate this demand.

References

1. Stockholm International Peace Research Institute (SIPRI). SIPRI Yearbook 2025: Armaments, Disarmament and International Security. Stockholm: SIPRI; 2025.
2. Garay J. Enough is Enough, and More is Too Much: Between Basic Dignity and Excess/Hoarding Thresholds. Policies for Equitable Access to Health (PEAH); 2024.
3. Garay J. Restoring the Broken Human Deal: Reframing Toxic GDP and Harmful Economic Allocation. Policies for Equitable Access to Health (PEAH); 2024 Apr 13.
4. Sustainable Health Equity Movement (SHEM). Webinar Series: Ethics and Metrics; Tax Justice as Step Toward Health Equity. Geneva: SHEM; 2023–2025.
5. Conscience and Peace Tax International. Advocacy for Peace Tax Funds and Conscientious Taxpayer Rights. International Civil Society Organization.
6. From Potsdam 1945 to Munich 2026: Technological Leap and Backward Trends in Global Governance, Inequality, and Planetary Health. Policies for Equitable Access to Health (PEAH); 2026 Feb.