News Flash 684: Weekly Snapshot of Public Health Challenges

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 News Flash 684

Weekly Snapshot of Public Health Challenges

 

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Debt, Financial Speculation and Artificial Intelligence: The Emerging Architecture of Inequity  by Juan Garay 

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Debt, Financial Speculation and Artificial Intelligence: The Emerging Architecture of Inequity

IN A NUTSHELL
Author's note
Public and private debt, financial speculation and artificial intelligence are converging to reshape the global distribution of wealth, power and opportunity. Debt creates contractual claims on future income; financial markets transform these claims into tradable assets; and increasingly sophisticated algorithms enable capital to be analysed, allocated and mobilised at unprecedented speed and scale. These mechanisms can finance productive investment and improve economic coordination. Yet, when governed primarily by private returns rather than social needs, they can also reinforce wealth concentration, amplify systemic risk and constrain the resources available for health, social protection and ecological transition.

Building on Karl Marx’s analysis of public debt, Thomas Piketty’s work on wealth concentration, contemporary research on financial stability, and Juan Garay’s previous publications on WiSE, algorithmic power, Palantir, “unplugging” and living communities, this article examines the mechanisms connecting debt, speculation and AI-driven decision-making. It argues that the central challenge is not technological progress or borrowing per se, but the concentration of control over financial and informational infrastructures and the unequal distribution of their benefits and risks.

From the perspective of the Sustainable Health Equity Movement (SHEM), the article proposes a framework for assessing financial and technological systems according to their contribution to human dignity, sustainable wellbeing and planetary health. It concludes by exploring how democratic financial governance, fair taxation, shared knowledge and interconnected communities can challenge structural dependency and build alternatives grounded in solidarity, sufficiency and ecological responsibility.

By Juan Garay  *

Co-Chair, Sustainable Health Equity Movement (SHEM)

Professor and Researcher in Health Equity, Ethics and Metrics

Founder, Valyter Ecovillage

Debt, Financial Speculation and Artificial Intelligence: The Emerging Architecture of Inequity

 

1.   Introduction: Three forces, one structural challenge

Debt, financial speculation and artificial intelligence are often discussed separately. Debt is treated as a fiscal or macroeconomic problem, speculation as a feature of financial markets, and AI as a technological revolution. Yet their interaction deserves much greater attention.

Debt creates obligations to transfer future income to creditors. Financial markets allow those obligations and other claims on future income to be traded, aggregated and used as collateral. Artificial intelligence increasingly supports the analysis of these assets, the assessment of risks and the automation of investment decisions.

Together, these processes can increase the capacity to mobilise capital. They can also strengthen the position of actors who already control large financial resources, privileged access to information and the technological infrastructure through which decisions are made.

The result is not necessarily a coordinated conspiracy or an inevitable outcome of technological progress. It is a structural possibility arising from the interaction of incentives, ownership, market concentration and unequal bargaining power.

The central question is therefore not simply how much debt exists or how powerful AI becomes. It is who controls these systems, whose interests they serve, who captures their benefits and who bears their costs.

This question is particularly important for the Sustainable Health Equity Movement (SHEM). In Achieving Sustainable Health Equity, Castro, Marmot, Garay, de Negri and Buss (2022) connect health inequities to the unequal distribution of power and resources, environmental damage and political conflict. Their analysis suggests that the consequences of financial and technological arrangements must ultimately be evaluated against their effects on people’s opportunities to live healthy and dignified lives.

2.   Debt: A liability for one party, an asset for another

Debt is not merely a number on a government’s balance sheet. It is a relationship between a borrower and a creditor, governed by contractual obligations and unequal economic circumstances.

For the borrower, debt means a commitment to make future payments. For the creditor, it represents a financial asset that may generate interest, be sold to another investor or serve as collateral for additional borrowing.

This dual character is essential to understanding the political economy of debt.

Public borrowing can finance hospitals, education, transport, renewable energy and infrastructure whose benefits extend across generations. Private borrowing can help households secure housing and enable companies to invest in productive capacity. Credit is indispensable to many modern economies.

The problem arises when borrowing becomes unsustainable, when its benefits are distributed unequally, or when repayment obligations undermine essential social functions.

Karl Marx examined this historical relationship in Capital, Volume I, Chapter 31, describing public credit as “one of the most powerful levers of primitive accumulation” (Marx, 1867, ch. 31).

His argument connected public borrowing to taxation, colonial expansion and the historical concentration of capital. The contemporary relevance lies not in assuming that every modern debt instrument reproduces the conditions of nineteenth-century capitalism, but in recognising that financial contracts operate within wider structures of ownership and political power.

A government can borrow to improve collective wellbeing. It can also borrow under conditions that transfer a substantial share of public revenue to creditors while limiting its capacity to provide essential services.

These outcomes are not equivalent.

Nor should all creditors be treated as a homogeneous group. Government bonds may be held by pension funds, insurance companies, central banks, investment funds and individual savers. Understanding the distributional consequences of public debt requires examining the actual ownership of financial assets, the terms of borrowing, the tax system and the public expenditure displaced by debt service.

The essential questions are:

  • Who receives the proceeds of borrowing?
  • Who owns the resulting financial claims?
  • What interest and repayment conditions apply?
  • Who pays the taxes or bears the spending reductions needed to service the debt?
  • Does the borrowing expand society’s long-term capacity to provide dignified lives?

Debt should be assessed not only through its financial sustainability but also through its social purpose and distributional consequences.

3.   From borrowing to speculation: When future income becomes a financial asset

Financial markets enable investors to buy and sell claims on future income. Government bonds, corporate debt, mortgages and other financial instruments can be traded in secondary markets or incorporated into more complex investment strategies.

This capacity can improve liquidity, distribute risk and help allocate capital. But it can also create incentives for financial activity increasingly detached from the production of goods and services or the provision of essential needs.

Leverage is particularly important. By borrowing to purchase assets, investors can increase the potential return on their own capital. When prices rise, the gains may be amplified. When prices fall, losses can also multiply, potentially forcing investors to sell assets, reduce lending or seek additional liquidity.

A reinforcing cycle can emerge:

  1. Credit finances the purchase of
  2. Rising asset prices increase the value of
  3. Stronger collateral enables additional
  4. New borrowing increases demand for
  5. Expectations of continued appreciation encourage further

This process may support productive investment for a time. However, if valuations and borrowing rise faster than the underlying capacity to generate sustainable income, the system becomes vulnerable to a reversal.

The same mechanism can affect public finance. When governments face rising borrowing costs, refinancing becomes more expensive. Countries with large external debts, limited access to foreign currency or weak fiscal capacity may find their policy choices increasingly constrained.

Debt does not automatically produce speculation, and speculation does not always create instability. The risk emerges when leverage, concentrated ownership, short-term incentives and interconnected financial institutions reinforce one another.

The critical distinction is between finance that supports productive and socially useful activity and financial expansion that increasingly depends on rising asset prices, refinancing and expectations of future returns.

4.   Inequality and the distribution of financial returns

The distributional consequences of debt depend on the relative positions of borrowers and creditors.

Households with limited income may need to borrow to obtain housing, cover emergencies or meet essential expenses. Their ability to negotiate interest rates and repayment conditions may be limited.

By contrast, institutions and individuals with substantial financial assets may have access to diversified portfolios, professional advice and cheaper sources of credit. They can earn interest, receive dividends, collect rents and benefit from capital gains.

This does not mean that every debtor is poor or every creditor wealthy. It means that unequal initial access to assets and credit can produce unequal opportunities to benefit from the financial system.

Thomas Piketty’s Capital in the Twenty-First Century (2014) draws attention to the capacity of accumulated wealth to reinforce inequality across generations. His well-known relationship between the return on capital and economic growth, expressed as (r>g), highlights one mechanism through which wealth concentration can persist.

Piketty does not present this relationship as an unconditional law. Its effects depend on institutions, taxation, inheritance, economic growth and political choices. Nevertheless, where wealth generates returns that persistently exceed the growth of ordinary incomes, the relative position of asset owners may strengthen over time.

Financialisation can intensify this divergence when returns from asset ownership grow faster than wages or public resources available for essential services.

The result is a potentially self-reinforcing cycle: concentrated wealth provides access to capital, access to capital creates additional investment opportunities, and investment returns expand the capacity to acquire further assets and influence economic decisions.

The issue is not merely the amount of wealth in society, but the concentration of ownership and the ability to convert financial resources into lasting economic and political power.

5.   Artificial intelligence: The acceleration of financial decision-making

Artificial intelligence is changing how financial institutions process information, evaluate risks and allocate capital.

Algorithms can analyse large datasets, model scenarios, detect patterns, estimate creditworthiness and support trading or portfolio management. These tools can improve efficiency and help institutions respond to complex conditions.

BlackRock’s Aladdin platform, for example, provides investment and risk-management technology used to analyse portfolios and market exposures. It illustrates the growing importance of digital infrastructure in the management of financial assets.

The existence of such systems does not mean that a single institution controls the global financial system or that all investment decisions are automated. It does demonstrate that advanced information technology has become an important component of financial power.

Juan Garay’s article, The Progressive Power of Data and Algorithms, and Their Effect on Human Life Loss Due to Geopolitical Tensions, Military Spending, and Global Injustice (2026a), examines the growing interaction between algorithmic infrastructures, financial concentration, military systems and global inequity. It argues that unequal access to data-processing and predictive capabilities can strengthen existing asymmetries of power.

The underlying concern is broader than any single platform. When a relatively small number of institutions control essential financial and technological infrastructures, they can acquire advantages in information, speed, scale and influence.

These advantages may improve investment decisions, but they can also make markets more dependent on concentrated providers and less transparent to regulators, workers and citizens.

The risks include:

  • Opacity: complex models may make decisions difficult to explain or challenge
  • Concentration: the costs of advanced computing and data infrastructure can favour large institutions.
  • Common-model risk: similar algorithms may react to the same signals, amplifying market movements.
  • Unequal access: institutions with better data and computing capacity may gain advantages over smaller participants.
  • Accountability gaps: responsibility may become difficult to establish when human decisions are mediated by automated systems.

AI does not need to possess intentions or independently seek domination to contribute to these outcomes. The relevant question is how its design, ownership and deployment interact with the incentives of the institutions using it.

6.   The feedback loop between debt, speculation and AI

The interaction between debt, financial speculation and AI can create a feedback loop that amplifies both growth and instability.

First, credit expands investment capacity. Borrowers use debt to purchase assets, develop businesses or finance technological infrastructure.

Second, expectations shape asset valuations. Investors assess the future income and potential appreciation associated with those assets. Optimistic expectations can increase demand and raise prices.

Third, algorithms accelerate analysis and transactions. Automated systems process information and respond to market signals at scales and speeds that can exceed conventional human decision-making.

Fourth, rising valuations support additional borrowing. Higher asset prices may increase collateral values, enabling further credit and additional investment.

Fifth, a change in expectations can reverse the process. Falling prices weaken collateral, increase refinancing difficulties and trigger sales. If many institutions react simultaneously, liquidity can deteriorate and losses can spread through interconnected markets.

The outcome depends on leverage, market structure, liquidity, regulatory safeguards and the quality of the underlying assets. It is not inevitable that AI will amplify a crisis.

Well-designed systems and effective oversight may improve risk detection.

Nevertheless, algorithmic speed can become a source of fragility when multiple institutions rely on similar signals, pursue comparable strategies or attempt to reduce exposure at the same time.

This is particularly relevant to investments associated with AI itself. Technological innovation can create substantial productive value, but expectations about future returns may also become excessive. If investment, valuations and borrowing grow faster than the revenue and productivity that eventually materialise, a correction can affect investors, lenders and the wider economy.

The International Monetary Fund’s work on AI and financial stability provides a useful framework for assessing these risks. Its Global Financial Stability Report and research on AI adoption should be read alongside national regulatory assessments and evidence on actual market exposures.

The central issue is not whether AI investment is good or bad. It is whether the financial commitments built around it remain sustainable under less optimistic conditions.

7.   Algorithmic power, surveillance and the Palantir question

Financial AI is only one dimension of a wider transformation in the relationship between data, technology and power.

In The Revolution of Harmony Against the Palantir Manifesto: Digital Control, Permanent Warfare, and the Defense of Human Freedom, Garay (2026b) examines the convergence of algorithmic systems, military applications, surveillance and political authority.

The article contrasts technologies that support human autonomy with systems that may strengthen surveillance, militarisation and centralised control. It argues for a different technological orientation, grounded in cooperation, ecological responsibility and the protection of human dignity.

This perspective matters to the debt debate because financial and informational power are increasingly interconnected. Large financial institutions use data to allocate capital and evaluate risk. Governments use digital systems to manage public administration and security. Technology companies provide infrastructure used in both civilian and military settings.

These systems have different purposes and governance arrangements; they should not be treated as interchangeable. Nor does their coexistence prove that they operate as a single coordinated system.

But their interactions raise legitimate questions about the concentration of decision-making power.

Who controls the data used to determine credit access, insurance costs, employment opportunities or public resource allocation? Who can challenge an algorithmic decision? What happens when critical infrastructure is owned by a small number of private providers? How can democratic institutions retain effective oversight when technical systems become increasingly complex?

The answer should not be technological rejection. It should be transparent governance, independent scrutiny, meaningful human accountability and the development of public-interest technological capabilities.

The same principle applies to financial AI: the more consequential a system’s decisions, the stronger the requirements for transparency, oversight and redress.

8.   From financial inequality to health inequity

For SHEM, the ultimate significance of these mechanisms lies in their consequences for human wellbeing.

Debt-service obligations can constrain public budgets. Financial instability can reduce employment, household security and access to credit. Wealth concentration can influence political priorities and the distribution of essential resources. Technological inequalities can determine who benefits from innovation and who remains excluded.

These mechanisms may affect health through several pathways.

Fiscal displacement

When governments devote increasing resources to servicing unsustainable debt, they may have less fiscal space for primary healthcare, education, housing, nutrition and social protection. The impact depends on national circumstances and policy decisions, but the opportunity cost can be substantial.

Household insecurity

High borrowing costs, housing debt and insecure income can increase financial stress and reduce households’ ability to afford nutritious food, healthcare and adequate living conditions.

Unequal technological access

AI may improve diagnosis, health surveillance, research and resource allocation. But where access to computing, data, infrastructure and skilled personnel is unequal, the benefits may accrue disproportionately to wealthier populations and countries.

Ecological harm

Financial incentives that favour environmentally destructive activities can contribute to pollution, biodiversity loss and climate disruption. The resulting health costs may be borne by populations that receive little of the financial benefit.

Political and military expenditure

Financial and technological systems also influence how resources are mobilised for defence and security. Military spending can serve legitimate public purposes, but its scale and allocation should be assessed alongside unmet health, social and ecological needs.

Castro et al. (2022) provide a relevant foundation for this analysis by linking sustainable health equity to the distribution of power and resources and to environmental and political conditions.

From this perspective, financial performance cannot be the sole measure of economic success. A system that generates substantial returns while worsening preventable mortality, undermining public services or accelerating ecological destruction must be evaluated against those social costs.

9.   The opportunity cost of financial and technological priorities

Every allocation of resources has an opportunity cost. Capital, energy, skilled labour, public revenue and institutional capacity used for one purpose cannot simultaneously be used for another.

Some financial activities create substantial social value. Others primarily redistribute existing claims, increase leverage or pursue short-term price movements. Similarly, AI can support scientific research, public health and environmental monitoring, or it can be deployed in ways that intensify surveillance, excessive consumption and financial concentration.

The distinction is not always straightforward, and financial markets cannot be reduced to a simple opposition between productive and unproductive activity. Liquidity, risk management and investment are necessary functions.

Nevertheless, society should ask whether its financial and technological capabilities are aligned with its most urgent needs.

What if more investment and technological expertise were directed towards strengthening primary healthcare, developing affordable medicines, restoring ecosystems, improving energy efficiency, supporting regenerative agriculture and ensuring access to clean water?

Such a reorientation would not happen automatically. It would require public investment, appropriate incentives, effective regulation and institutions capable of identifying and supporting activities with high social value.

The central problem is a possible divergence between private profitability and collective benefit. An activity may be highly profitable without meeting an urgent social need, while another may generate enormous public benefits without offering investors an attractive financial return.

Public policy must address this divergence rather than assuming that market prices alone will determine the most socially desirable allocation of resources.

10.   From financial accumulation to Wellbeing in Sustainable Equity (WiSE)

Garay’s earlier work on Wellbeing in Sustainable Equity (WiSE) offers a normative framework for addressing this challenge.

In Towards a WISE – Wellbeing in Sustainable Equity – New Paradigm for Humanity (2023), Garay proposes that economic and political arrangements should be assessed according to their capacity to support dignified, healthy lives while respecting ecological limits and intergenerational responsibilities.

This framework challenges the assumption that growth in monetary output is sufficient evidence of social progress. It instead asks whether resources are distributed fairly, whether people can attain good health and wellbeing, and whether present consumption undermines the opportunities of future generations.

The Sustainable Wellbeing Equity Index (Garay, 2025) develops this direction through an ethical approach to wellbeing that considers both individual flourishing and the consequences of excessive accumulation for others and for the natural world.

Applied to debt and AI, WiSE suggests three complementary tests.

The dignity test: Does a financial or technological arrangement expand access to the material and social conditions necessary for a dignified life?

The equity test: Who benefits, who bears the risks and costs, and does the arrangement reduce or reinforce unjust inequalities?

The sustainability test: Are the activity’s ecological consequences compatible with the long-term conditions for human and planetary health?

These tests do not replace conventional financial analysis. They complement it by making explicit the social and ecological consequences that market prices may fail to capture.

They also provide a basis for developing indicators that compare debt service with essential public expenditure, assess the distribution of financial returns and examine who benefits from AI-driven productivity gains.

11.  “Unplugging”: Reducing dependence on extractive systems

In The Health, Equity, Peace, and Planetary Value of “Unplugging” (Garay, 2026c), the concept of unplugging is presented as more than a personal lifestyle choice. It is a potential strategy for reducing dependence on systems characterised by hyperconnectivity, surveillance, financial concentration, ecological extraction and excessive consumption.

The argument is not that people should abandon technology or withdraw from society. It is that individuals and communities can strengthen autonomy by reducing unnecessary dependence on systems that intensify stress, compulsive consumption and social fragmentation.

The concept has an economic dimension. Communities that cultivate food, share tools, repair equipment, generate renewable energy and exchange knowledge can reduce some of their dependence on distant markets and concentrated suppliers.

These practices cannot eliminate the need for national institutions, specialised healthcare, international trade or sophisticated technological infrastructure. Nor should responsibility for structural inequality be transferred to individuals expected to solve it through personal choices alone.

Their value lies in complementing institutional reform with practical alternatives.

Unplugging can mean reducing dependence on systems whose incentives are misaligned with wellbeing while reconnecting economic activity to ecological limits, social relationships and meaningful work.

In this sense, community autonomy and global cooperation are not opposites. Local resilience can reduce vulnerability, while wider networks provide access to knowledge, specialised resources and solidarity that individual communities cannot generate independently.

12.   From individual resilience to networks of ecovillages and flotillas

Reducing dependence on global markets can begin at the individual level, through choices that strengthen self-reliance, sufficiency and mutual aid. People can reduce unnecessary consumption, cultivate food where possible, repair and share goods, use local services, develop practical skills and participate in cooperative forms of production and exchange. These actions do not imply isolation from the wider economy; rather, they can reduce vulnerability to volatile prices, debt, monopolistic suppliers and extractive consumption patterns.

At the community level, the same principle can become institutional. Ecovillages, cooperatives, community land trusts, local energy systems, seed networks, repair workshops, shared transport and solidarity economies can retain more value locally while strengthening social relationships and ecological stewardship. Such communities can experiment with forms of governance in which essential resources are treated as commons rather than merely as commodities.

The objective is not to romanticise localism or suggest that every community can meet all its needs independently. Modern societies require specialised knowledge, healthcare, infrastructure and forms of international cooperation. The aim is instead to build a diversified network of local capacities that reduces excessive dependence on distant and concentrated systems while remaining open to reciprocal exchange.

At the national level, governments can support this transition through public procurement from cooperatives and local producers, decentralised renewable energy, regional food systems, public digital infrastructure, universal basic services, fair taxation and investment in resilient transport, health and education. National policy can also reduce exposure to volatile global markets by strengthening domestic productive capacity and democratic control over essential resources.

Progress towards a network of ecovillages can therefore be understood as a gradual rebalancing between local autonomy and wider solidarity. Connected communities could exchange knowledge, technologies, seeds, medicines, educational resources and emergency support without reproducing the logic of financial dependency. Digital tools, when governed as public-interest infrastructure, could help coordinate these networks while protecting privacy and democratic accountability.

The idea of flotillas extends this vision to the maritime and international sphere. Cooperative flotillas could support ecological restoration, humanitarian assistance, scientific research, sustainable fisheries, ocean monitoring and peaceful cultural exchange. They could connect coastal communities and island societies in networks based on mutual aid rather than military competition or extractive trade. Their purpose would be to demonstrate that mobility, technology and international connection can serve life, peace and ecological care.

Such networks could also challenge the political economy of arms trade and war. By redirecting public attention and resources towards health, climate adaptation, food security, ecological restoration and human development, ecovillages and flotillas could expose the opportunity costs of militarisation. They could create visible forms of transnational cooperation that contest the assumption that security depends primarily on weapons, permanent military expansion and geopolitical domination.

This does not mean that local communities or civil society networks can end wars by themselves. Arms production, military alliances and geopolitical conflicts require national and international political action. However, networks of autonomous and cooperative communities can strengthen peace constituencies, document the human and ecological costs of militarisation, support affected populations and advocate for arms-control agreements, demilitarisation and the conversion of military industries towards socially useful production.

The broader ambition is to move from dependence on global markets organised around debt, speculation and arms competition towards interdependent networks organised around sufficiency, cooperation and shared wellbeing. At the individual, community and national levels, reducing dependency should not mean withdrawing from humanity; it should mean creating the capacities needed to participate in global solidarity on more equal and peaceful terms.

13.   Policy directions: Governing debt, finance and AI for the common good

The preceding analysis suggests a set of practical priorities.

13.1.   Make debt transparent and socially accountable

Public borrowing should be evaluated not only through repayment capacity but also through its purpose, distributional effects and long-term contribution to collective wellbeing.

Governments should disclose relevant borrowing conditions, guarantees and risks, while protecting legitimate confidentiality. Where debt becomes unsustainable, restructuring should be timely and fair, with safeguards against disproportionate harm to essential public services.

13.2.   Strengthen fair taxation and reduce excessive concentration

Progressive taxation, effective action against tax evasion and illicit financial flows, and the review of unjustified fiscal privileges can help finance public goods and reduce the political influence associated with extreme wealth concentration.

The objective is not to discourage all saving or productive investment. It is to ensure that the benefits of economic activity contribute fairly to the societies that make it possible.

13.3.   Monitor systemic financial risk

Regulators should assess leverage, interconnected exposures, liquidity risks and the effects of common algorithmic strategies across financial institutions.

Oversight must extend to relevant activities outside traditional banking where these can generate systemic vulnerabilities. Stress testing should consider not only conventional financial shocks but also sudden changes in AI-related valuations and the concentration of critical technological infrastructure.

13.4.   Require accountability for consequential AI

Financial and public-sector AI systems should be subject to appropriate risk assessment, independent scrutiny, meaningful human oversight and accessible mechanisms for challenging harmful decisions.

Institutions should disclose sufficient information about the purpose and limitations of consequential systems to enable effective supervision without compromising legitimate security or privacy protections.

13.5.   Share the gains from automation

Where AI and automation increase productivity, institutions should consider how the benefits can support better wages, shorter working hours, skills development, social protection and improved public services.

Productivity gains should not automatically accrue to capital owners while workers face insecurity and communities absorb the social costs of economic restructuring.

13.6.   Finance global public goods

Primary healthcare, disease prevention, education, climate adaptation, ecological restoration and scientific research generate benefits that often extend beyond national borders and cannot be adequately financed through private returns alone.

Public finance and international cooperation remain essential to ensuring that these benefits reach populations with the greatest needs and the least purchasing power.

13.7.   Support local and cooperative resilience

National and international policy should support ecovillages, cooperatives, community land trusts, local renewable energy, regenerative agriculture, repair and reuse systems, and other initiatives that reduce unnecessary dependence on volatile global markets.

Funding mechanisms should favour community ownership, open knowledge and democratic governance rather than concentrating infrastructure and data in a small number of private actors. Public procurement, technical assistance and fair access to credit can help local networks become viable without imposing unrealistic expectations of complete self-sufficiency.

13.8.   Redirect resources from militarisation towards peace and wellbeing

Governments and international institutions should assess military expenditure alongside unmet health, social and ecological needs. Greater transparency in arms production and trade, stronger controls on arms transfers, support for conflict prevention and the conversion of military industries towards renewable energy, public transport, health technologies and ecological restoration can help reduce the structural drivers of war.

Civil-society networks, ecovillages and flotillas can complement these measures by building peaceful cooperation, supporting affected communities and demonstrating practical alternatives to militarised security.

13.9.   Measure what matters

Financial indicators should be complemented by measures of health, wellbeing, distribution and ecological sustainability.

Within the SHEM framework, this could include tracking the relationship between debt service and essential public spending, the distribution of financial ownership, access to AI infrastructure, the allocation of productivity gains and the effects of economic policy on preventable mortality and environmental health.

Measurement alone cannot resolve political conflict. But transparent evidence can clarify trade-offs, expose avoidable deprivation and strengthen democratic accountability.

14.   Conclusion: From financial dependency to living communities

Debt, financial speculation and artificial intelligence are not inherently destructive. Each can contribute to productive investment, scientific progress and the coordination of complex societies. Their consequences, however, depend on who controls them, whose interests they serve and how their benefits, risks and costs are distributed.

When debt finances essential capabilities, it can expand collective freedom. When public revenues are increasingly committed to servicing debt held by financial institutions and investors, while essential needs remain unmet, debt can become a mechanism through which taxpayers transfer resources to asset owners. When speculation and leverage reward short-term financial returns over long-term social and ecological value, the result can be greater inequality, instability and environmental destruction. And when AI accelerates these processes without democratic accountability, it risks concentrating economic and informational power even further.

The challenge is therefore not simply to regulate individual financial instruments or technological platforms. It is to reconsider the purpose of the economic system itself.

Who should benefit from humanity’s productive capacity, accumulated knowledge and technological intelligence? Should these resources primarily serve the multiplication of financial assets, or should they guarantee the conditions for dignified lives, equitable wellbeing and the protection of the living world?

The Sustainable Health Equity Movement (SHEM) and its WiSE framework offer an ethical basis for answering this question. Economic progress should be assessed by its contribution to health, dignity and sustainable equity, rather than by monetary growth alone. Valyter, through its commitment to courage and tenderness, ecological regeneration, shared learning and community autonomy, seeks to put these principles into practice.

Communities as a practical challenge to extractive globalisation

In A New Horizon: From Broken Systems to Living Communities, Garay (2026d) develops the vision of a global network of ecovillages, permaculture initiatives and solidarity flotillas. These are not proposed as isolated refuges from the world, but as connected, self-governing communities that can demonstrate different ways of producing, sharing and caring for life.

Such communities can challenge the assumption that wellbeing requires ever-expanding global trade, unnecessary consumption and the constant movement of people and goods over long distances. International exchange remains essential for scientific cooperation, cultural encounter, specialised knowledge and the equitable sharing of resources. The challenge is to distinguish trade that meets genuine needs from trade driven primarily by artificial demand, planned obsolescence, speculative opportunities and the externalisation of environmental costs.

A sustainable economy would encourage durable goods, repair and reuse, local and regional food systems, renewable energy, shared transport and meaningful human mobility. It would reduce unnecessary travel and resource-intensive consumption without restricting people’s freedom to explore, migrate, learn or maintain relationships across borders. The objective is not isolation, but greater autonomy, less waste and more purposeful interdependence.

Communities can also challenge the privatisation of knowledge and resources that should serve as global public goods. Essential medicines, publicly funded research, life-saving technologies, seeds, scientific knowledge and tools needed for ecological restoration raise fundamental questions about the limits of patents and exclusive ownership. Intellectual property can support innovation, but it should not become an absolute barrier to essential goods or prevent humanity from responding collectively to health emergencies and ecological crises. Open science, knowledge commons, fair licensing and technology transfer can help ensure that innovation serves human needs rather than only purchasing power.

The question of taxation and perpetual debt service

A further challenge concerns the use of public taxation. Taxes are essential to finance healthcare, education, social protection, infrastructure and the institutions that make collective life possible. But the legitimacy of taxation is undermined when governments repeatedly ask citizens to contribute while a substantial share of public revenue is committed to debt service, financial rescues or obligations whose benefits are disproportionately captured by creditors and asset owners.

The issue is not that all debt service is illegitimate, or that every creditor represents speculative capital. Public debt is held by diverse institutions and individuals, and borrowing can serve essential social purposes. The ethical question is whether the terms, ownership and consequences of debt are compatible with democratic accountability and the common good.

When unsustainable debt obligations restrict public investment in essential services, while financial returns accrue disproportionately to those who already own wealth, fiscal policy can reproduce the very inequalities it should correct. When capital continues to finance extractive activities whose environmental and health costs are transferred to society, taxpayers and future generations effectively bear costs that are not reflected in private returns.

This calls for transparent public debt, fair taxation, action against tax avoidance and illicit financial flows, timely and equitable debt restructuring where necessary, and scrutiny of the social opportunity costs of debt service. It also requires redirecting public and private finance towards healthcare, education, ecological regeneration, renewable energy, sustainable food systems and other global public goods.

From local autonomy to global solidarity

No ecovillage can solve global inequality alone. Communities cannot replace universal healthcare, international climate agreements, democratic institutions or the political action needed to reform financial markets and prevent war. Nor should local autonomy become an excuse for governments to abandon their responsibilities.

The value of communities lies instead in their capacity to demonstrate, learn and connect. Ecovillages can regenerate ecosystems, share seeds and knowledge, reduce dependence on concentrated suppliers and practise forms of governance based on cooperation. Cooperatives and local commons can retain more value within communities. Solidarity flotillas can connect territories and peoples through humanitarian assistance, scientific exchange, cultural encounter and peaceful resistance to injustice.

Linked through networks of reciprocal support, these initiatives can help create a different relationship between local autonomy and global cooperation. Digital technology, when developed as accountable public-interest infrastructure, can support this network without making it dependent on surveillance, proprietary platforms or the concentration of data and decision-making power.

Such a transformation also challenges the logic of permanent militarisation. Resources devoted to arms races, warfare and geopolitical domination have opportunity costs in lives, health, social development and planetary integrity. Communities and transnational solidarity networks cannot end war by themselves, but they can strengthen peace movements, support affected populations and demonstrate that security can also be built through cooperation, resilience and the protection of essential needs.

The transition must take place at several levels: individuals choosing sufficiency over compulsive consumption; communities building shared capacities and ecological resilience; nations protecting public goods and reforming taxation and debt governance; and international networks ensuring that knowledge, technology and essential resources are shared more equitably.

The ultimate ambition is not to disconnect humanity from the world, but to unplug from systems of dependency and extraction in order to reconnect with one another and with the living planet.

Debt should finance capabilities, not dependency. Finance should serve society, not govern it. Artificial intelligence should expand human autonomy, not concentrate power over our lives. Trade should meet human needs without exceeding planetary limits.

Knowledge should advance the common good, and taxation should sustain collective wellbeing rather than perpetuate unjust financial arrangements.

The measure of economic progress must ultimately be whether humanity can use its knowledge, resources and collective intelligence to prevent avoidable suffering, restore the natural world and ensure that every person has a fair opportunity to flourish.

The horizon is not a world without exchange, technology or institutions. It is a world in which these serve life; where financial systems are accountable to society, global cooperation respects planetary boundaries, and living communities offer practical foundations for a more equitable and peaceful future.

The real alternative to broken systems is not withdrawal from humanity. It is the construction of living communities, connected in solidarity, capable of challenging financial dependency and demonstrating that another way of living together is possible.

 

References

Foundational works and international research

Bank for International Settlements (BIS). (2024). The intelligent financial system: How AI is transforming finance. BIS Working Papers. See BIS publications on AI, financial innovation and stability. https://www.bis.org/

BlackRock. Aladdin: Investment and risk management technology.

https://www.blackrock.com/aladdin

Castro, A., Marmot, M., Garay, J., de Negri, A., & Buss, P. (2022). Achieving sustainable health equity. Bulletin of the World Health Organization, 100(1), 81–83. https://doi.org/10.2471/BLT.21.286523

International Monetary Fund (IMF). (2024). Gen-AI: Artificial Intelligence and the Future of Work. Staff Discussion Note. https://www.imf.org/en/Publications/Staff-Discussion-Notes/Issues/2024/01/14/Gen-AI-Artificial-Intelligence-and-the-Future-of-Work-542379

International Monetary Fund (IMF). Global Financial Stability Report. See current editions and chapters on leverage, financial stability and technological risks. https://www.imf.org/en/Publications/GFSR

Marx, K. (1867). Capital: A Critique of Political Economy, Volume I. Chapter 31, “Genesis of the Industrial Capitalist.” https://www.marxists.org/archive/marx/works/1867-c1/ch31.htm

Piketty, T. (2014). Capital in the Twenty-First Century. Harvard University Press.

Piketty, T. (2015). Putting distribution back at the center of economics: Reflections on Capital in the Twenty-First Century. Journal of Economic Perspectives, 29(1), 67–88. https://doi.org/10.1257/jep.29.1.67

Juan Garay’s related publications in PEAH

These articles develop the ethical, political and practical arguments that underpin the present paper.

Garay, J. (2023). Towards a WISE – Wellbeing in Sustainable Equity – New Paradigm for Humanity. PEAH – Policies for Equitable Access to Health. Introduces the WiSE paradigm as an alternative framework for global wellbeing, equity and ecological sustainability.

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

Garay, J. (2025). The Sustainable Wellbeing Equity Index: An Ethical Reference to Wellbeing while Respecting Other Lives. PEAH. Develops an ethical approach to assessing wellbeing, inequality, excessive accumulation and ecological responsibility. https://www.peah.it/2025/01/14273/

Garay, J. (2025). Beyond Green Complacency: WISE, SHEM and the Case for Radical Sharing. PEAH. Critiques ecological approaches that leave structural inequality and excessive consumption unchallenged, proposing sufficiency, sharing and common resources.

https://www.peah.it/2025/10/15206/

Garay, J. (2026a). The Progressive Power of Data and Algorithms, and Their Effect on Human Life Loss Due to Geopolitical Tensions, Military Spending, and Global Injustice. PEAH. Examines the interaction between algorithmic infrastructures, financial concentration, military power and global inequity. https://www.peah.it/2026/04/the-progressive-power-of-data-and-algorithms-and-their-effect-on-human-life-loss-due-to-geopolitical-tensions-military-spending-and-global-injustice/

Garay, J. (2026b). The Revolution of Harmony Against the Palantir Manifesto: Digital Control, Permanent Warfare, and the Defense of Human Freedom. PEAH. Explores the relationship between AI, surveillance, militarisation, centralised power and the defence of human autonomy.

https://www.peah.it/2026/05/16031/

Garay, J. (2026c). The Health, Equity, Peace, and Planetary Value of “Unplugging”: Cortisol Dysregulation as a Biological “Plug-Indicator” of Immersion in Extractive Systems. PEAH. Connects hyperconnectivity, financial concentration, chronic stress, planetary health and community resilience.

https://www.peah.it/2026/05/16138/

Garay, J. (2026d). A New Horizon: From Broken Systems to Living Communities. PEAH. Develops a vision of interconnected ecovillages, permaculture and solidarity flotillas as practical alternatives to financial extraction, ecological destruction and systems of concentrated power.

https://www.peah.it/2026/05/a-new-horizon-from-broken-systems-to-living-communities/

SHEM and Valyter resources

Sustainable Health Equity Movement (SHEM). Concept Note.

https://www.sustainablehealthequity.org/concept-note

SHEM. Concepts and Metrics of Sustainable Health Equity.

https://www.sustainablehealthequity.org/concept-and-metrics

SHEM. Webinar Series.

https://www.sustainablehealthequity.org/webnair

Valyter. Latest News and Publications.

https://www.valyter.es/ultimas-noticias

—————————

By the same Author on PEAH: HERE

*  MD, internal medicine, MSc Trop Med, MPH, independent researcher and co-founder of the Sustainable Health Equity Movement (SHEM) and Valyter Ecovillage, a community initiative promoting shared living, care for nature and sustainable development. He has worked for more than three decades in public health, health equity and international cooperation. He served as Coordinator of the European Union Cooperation Programme on Global Health and for Mexico (2013–2017) and Cuba (2017–2023). He is  Visiting Professor at the Latin American School of Medicine (ELAM), the Marta Abreu Central University of Las Villas (UCLV) and the Agrarian University of Havana (UNAH) in Cuba; the Autonomous University of Chiapas (UNACH) in Mexico; Fundação Oswaldo Cruz (Fiocruz) in Brazil; the National School of Public Health (ENS) in Spain; and the University of California, Berkeley, USA. His research focuses on Sustainable Health Equity, global health, human development, international cooperation and the governance of knowledge and global public goods for the common good.

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Derna’s Flood Was a Climate and Health Warning for Libya

IN A NUTSHELL
Author's note
The article reflects on the health consequences of Storm Daniel and the lessons Derna’s recovery holds for climate-informed planning, health services and people affected by displacement.

Derna’s recovery will not be measured only by the speed of construction. It will be measured by whether residents and displaced people are safer, healthier and still able to get care when the next extreme event comes

By Meftah Lahwel 
MD, Master in Sustainability in Health 

 Derna’s Flood Was a Climate and Health Warning for Libya

What a City Rebuilding After Storm Daniel Can Teach Us About Climate Risk, Displacement and Care

 By the same Author on PEAH: HERE

Meftah Lahwel is a medical doctor and public health professional with more than a decade of humanitarian experience, including work with UNHCR, MSF and International Medical Corps. He holds a Master in Sustainability in Health at the University of Turin. His interests include refugee and migrant health, health systems and climate-related health risks

 

In my humanitarian health work, I have learned to ask a practical question: when someone needs care, can they actually reach it? The answer depends on more than whether a clinic is open. It depends on safe roads, clean water, functioning referrals and whether treatment continues when a family has to move. Derna brought all these questions together.

Storm Daniel struck northeastern Libya on 10–11 September 2023. In Derna, the failure of two dams sent floodwater through the city, destroying homes and essential infrastructure. The disaster unfolded in a country with divided institutions and two competing administrations: the Government of National Unity (GNU), based in Tripoli, and another government based in Benghazi. In October 2023, the UN Support Mission in Libya warned that competing recovery initiatives risked undermining reconstruction and called for a unified approach.

Derna’s flood history matters. Wadi Derna is usually dry, but it can carry powerful floodwaters. Historical accounts describe damaging floods in 1941, 1956, 1959 and 1968. Two dams were built upstream between 1973 and 1977. Later floods in 1986 and 2011 showed that the wadi remained a threat. Those events did not make the 2023 catastrophe inevitable. They did make the hazard known.

The climate signal also needs to be stated carefully. In its study, “Interplay of climate change-exacerbated rainfall, exposure and vulnerability led to widespread impacts in the Mediterranean region” the World Weather Attribution group estimated that human-caused climate change had made rainfall as extreme as that observed in Libya up to 50 times more likely and up to 50% more intense than in a climate 1.2°C cooler. The researchers stressed that these estimates carry significant uncertainty. Their analysis also examined how exposure and vulnerability shaped the impact: climate change intensified the rainfall hazard, while dam conditions, preparedness and the ability to communicate and act on warnings influenced the scale of the catastrophe.

The water crisis after the flood was immediate. UNICEF reported that half of Derna’s 18 boreholes were shut down and that damage to the sewage system raised concerns about groundwater contamination. UNICEF and other responders supported water delivery and repairs to water points. The ICRC, together with the Libyan Red Crescent, provided emergency drinking water and water and sanitation equipment. These actions helped meet urgent needs, but they also showed how closely health depends on services outside the clinic.

When water systems fail, the consequences reach households, shelters and health facilities. Safe water, sanitation and proper shelter help prevent illness and protect dignity. When roads are damaged, a referral may fail. When a family is displaced, a course of treatment may be interrupted. These are not separate problems to be solved by separate sectors; they are connected parts of people’s health.

The flood also struck a health system already under strain. WHO assessed 240 health facilities in affected areas in October 2023: 73% were partly functional, 14% non-functional and 13% fully functional. WHO supported the restoration of facilities and the establishment of field hospitals. For patients, these figures meant disrupted access to routine care, medicines, referrals and follow-up at the very time when needs were increasing.

Residents of Derna and other affected locations were displaced, and not everyone faced the same barriers to finding shelter or care. IOM’s November 2023 assessment estimated that 1,715 migrants were also displaced by the floods, most in northeastern Libya. That figure counts people displaced by the flood; it does not mean they had migrated because of climate change.

For public health, this distinction matters. People move for different reasons and have different access to money, documents, language, family networks and services. Displacement can interrupt care for chronic illness, pregnancy, children and mental health. A climate and migration perspective asks who can reach services, who is left out, and how care follows people when they move. Derna’s recovery must include all affected people: local residents, displaced Libyans, refugees, asylum-seekers and migrants, as well as communities hosting them.

The psychological impact was just as real as the physical damage. People faced bereavement, loss of homes and livelihoods, displacement and uncertainty. Health workers and rescuers were exposed to distress as they cared for others and responded to loss.

There was a coordinated MHPSS (Mental Health and Psychosocial Support) response. The government Benghazi established a mental health and psychosocial support committee under the Ministry of Health. WHO worked with local health authorities to provide services from psychological first aid to specialist psychiatric care. By 7 November 2023, the committee had deployed 45 MHPSS professionals to seven flood-affected locations. ACAPS (Assessment Capacities Project) later reported ten health facilities offering MHPSS services in Derna, Al-Bayda and Al-Marj, supported by WHO and partner organisations.

This response showed the value of local professionals working with health authorities and international organisations. It also exposed a longer-term challenge: emergency teams cannot provide continuity if local services are not funded, staffed and supported after the emergency phase. ACAPS called for sustained capacity-building, training and supervision. MHPSS belongs within the health system, not only in the first weeks after a disaster.

The recovery needs were substantial. A joint World Bank, EU and UN assessment estimated US$1.8 billion for reconstruction and recovery and recorded nearly 44,800 people initially displaced. By 2026, rebuilding in Derna is highly visible. New homes, roads and bridges matter to people rebuilding their lives. But reconstruction is not proof that risk has been reduced. A 2026 study “Integrating socio-economic impact assessment into the reconstruction plan for Derna, Libya” raised concerns that parts of the reconstruction reproduced vulnerable spatial patterns without comprehensive flood management or alternative planning frameworks. The question is therefore not only what has been rebuilt, but whether people are safer in the places where they live.

New buildings alone cannot prevent another disaster. Derna needs land-use and reconstruction planning based on flood and climate risk, regular inspection and maintenance of dams, early warnings that people understand and can act on, and evacuation plans designed with communities. Health facilities, water and sanitation systems, roads and shelters need to be treated as one protection network. Clinics need backup water and power, medicines, referral routes and ways to continue care when people are displaced.

My work supporting health services in Libya has taught me that resilience is felt in ordinary moments: when a patient can reach a facility, find safe water, receive a referral and return for follow-up. It is also felt by people on the move, who can lose access to care each time a service or border interrupts their journey. Derna’s recovery will not be measured only by the speed of construction. It will be measured by whether residents and displaced people are safer, healthier and still able to get care when the next extreme event comes.

 

 

 

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Developing a National Framework to Measure Health System Resilience to Communicable Disease Outbreaks: Early Lessons from Iran

IN A NUTSHELL
Author's note
A commentary here on developing a national framework to assess health system resilience to communicable disease outbreaks in Iran.

This article reflects on our experience, while working together with a multidisciplinary team at Iran’s Ministry of Health, of translating the concept of health system resilience into measurable indicators, and considering how resilience can be assessed across different levels of the health system

By Dr. Narges Roohi

PhD. Health in Disasters & Emergencies

Teheran, Iran

Developing a National Framework to Measure Health System Resilience to Communicable Disease Outbreaks

Early Lessons from Iran

 

Introduction

Health system resilience was discussed in the scientific literature before COVID-19 and gained prominence following the Ebola epidemic. COVID-19 further strengthened its place in health policy, management and research. The pandemic demonstrated that effective preparedness and response require coordination across the health system, continuity of essential services and adaptation to changing conditions, alongside disease control and clinical care. Experiences across countries during COVID-19 highlighted the importance of governance, financing, the health workforce, health information systems, service delivery, access to medical products and technologies, and public health functions in absorbing the effects of a shock, adapting and responding effectively.

In Iran, studies conducted during COVID-19 examined challenges in the health-system response, including managerial and organizational issues, and the resilience of healthcare facilities. The involvement of health policy-makers, managers and staff in some of these studies helped clarify implementation challenges. Findings emphasized coordination, resource management, workforce preparedness, health information systems and management capacity, underscoring the need for a health-system-wide approach to pandemic response.

A central question was how to translate the broad concept of health system resilience into components and indicators that could be measured and monitored. This challenge was not unique to Iran. In its 2020 report, Strengthening Health Systems Resilience: Key Concepts and Strategies, the European Observatory on Health Systems and Policies emphasized that resilience assessment should reflect the type of shock and the health-system context, and draw on a range of quantitative and qualitative measures.

In its 2021 position paper on health systems resilience, WHO emphasized linking health-system strengthening, health security, universal health coverage, primary health care and essential public health functions. COVID-19 had shown that addressing these areas separately could limit the capacity to respond to major crises.

In 2024, WHO’s Building Health System Resilience to Public Health Challenges: Guidance for Implementation in Countries provided a clearer pathway for putting this approach into practice. The guidance emphasizes adapting actions to country contexts and the roles of national and subnational actors, helping countries translate resilience into practical health-system interventions.

From global guidance to framework development in Iran

In Iran, this work began with the challenge of translating resilience into capacities that could be identified, assessed and strengthened in practice. In 2025, the Center for Communicable Disease Control at the Ministry of Health and Medical Education initiated the development of a framework adapted to the country’s health-system structure to assess capacities for preventing and responding to communicable disease outbreaks. The aim was to identify priorities for improvement and informed decision-making, with particular attention to the relationship between national policies and their implementation at subnational and service-delivery levels.

Framework development combined a review of international documents, including WHO’s health system resilience indicator package, with expert-led adaptation to the country’s structure and priorities. Preliminary meetings and the establishment of a steering committee enabled participation by specialists and operational managers in communicable diseases, primary health care, health-system management, disaster and emergency health, and biostatistics. Group discussions, documented comments and additional feedback supported iterative indicator refinement and expert consensus.

The framework covered six domains: governance, the health workforce, service delivery, health information systems, access to essential medicines and technologies, and health financing. The assessment level and evidence requirements were considered for each indicator. Pilot implementation in the Fardis County Health Network, involving local experts and Alborz University of Medical Sciences, enabled the framework’s application to be examined in practice. Policy and programme documents, administrative records and service-delivery records provided the evidence, which was reviewed collaboratively.

This commentary examines framework development and lessons from pilot implementation. As the project remains ongoing, detailed results, scores and quantitative comparisons are not reported here. The initial assessment was operational and exploratory and was conducted in one local setting. It therefore does not establish national health system resilience or the validity and reliability of the assessment tool.

Early lessons for assessment design and interpretation

First, each indicator requires a clearly defined assessment level and implementation responsibility. Some capacities concern national policy-making, others depend on coordination at provincial and district levels, and others are assessed at service-delivery units. Reviewing national documents within a local pilot does not, by itself, support conclusions about national performance. Comparisons across levels must also account for differences in the sets of applicable indicators.

Second, structural non-applicability must be distinguished from missing data and an unmet capacity. A blank assessment cell does not necessarily indicate poor performance: the indicator may not apply at that level under the framework’s design. Defining this distinction is essential for selecting appropriate denominators and interpreting results correctly, and should be addressed during framework development.

Third, the existence of an approved policy or plan does not, by itself, demonstrate effective implementation. Joint review of documentation can clarify the relationship between formal commitments, organizational responsibilities and local implementation. However, documentation alone cannot establish that essential services will be maintained during an actual shock. Subsequent assessments should complement evidence on capacities with evidence on health-system performance during crises, service continuity and learning after events.

Fourth, relying solely on an overall score may obscure important implementation gaps. An assessment has greater policy value when each priority for improvement is linked to a specific corrective action, a responsible actor, required resources and a follow-up timetable. Assessment findings should therefore inform implementation priorities and the monitoring of corrective actions.

Project continuity amid armed conflict

The project was implemented amid escalating regional armed conflict. Direct conflict between Iran and Israel in April 2024 formed part of the security context preceding the project. The 12-day war began on 13 June 2025, with direct US military involvement on 22 June, followed by joint US and Israeli attacks on Iran on 28 February 2026. According to the implementation team’s experience, hostilities during the project period substantially delayed its progress. This commentary does not quantify the delays or assess the pathways through which the conflict affected implementation.

This experience demonstrates the need to plan for continuity of resilience assessment and strengthening activities during crises. Flexible timelines, systematic documentation of decisions, preservation of records and arrangements for phased implementation could inform future planning. The project delay is reported as an implementation experience; it does not, by itself, provide a basis for assessing the resilience of the entire health system.

Policy implications and next steps

Before wider implementation, the framework requires evaluation of content validity, inter-rater reliability, test–retest reliability, completion time, implementation burden and acceptability across different settings. Completing an assessment in one local setting demonstrates that initial application was possible, but does not establish feasibility at scale or the generalizability of findings. Scoring thresholds should be presented as operational programme benchmarks and, until validated, should not be used to classify a health system definitively as resilient or non-resilient.

Further framework development should incorporate health equity through explicit assessment questions: are essential services maintained for vulnerable groups during crises? Are geographic and financial barriers to access reduced? Does resource allocation reflect the differing needs of population groups? These questions are proposed priorities for future framework development, rather than reported project findings. WHO’s position paper on resilience, universal health coverage and health security provides the conceptual basis for this direction.

Iran’s early experience suggests that developing a national resilience measurement framework requires clearly assigned implementation responsibilities, transparent rules for interpreting evidence and a defined pathway from assessment findings to decision-making, alongside indicator selection. As the project continues, the framework’s practical value should be evaluated in terms of its contribution to corrective action, continuity of essential services and reduced health inequities during crises.

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