Overuse and inappropriate use of antimicrobials is driving bacterial, viral and parasite resistance to common drugs

Action is lagging far behind the milestone commitments of the 2024 UN High Level Declaration on Antimicrobial Resistance (AMR). But a Ministerial Meeting scheduled for 6-8 December in Abuja offers an opportunity to pick up the baton. Ahead of that, civil society gropus will convene in mid-November in Rome. 

Two years after the UN General Assembly pledged to reduce deaths from AMR 10% by 2030, the world is losing the battle against superbugs. And UN institutions vested with leading the charge against the proliferation of drug resistant pathogens are plagued by budget cuts and leadership questions. According to WHO, some 4.9 million deaths annually are somehow associated with AMR, while a 2022 Lancet study found 1.27 million deaths were a direct result of superbug resistance to antibiotic treatment. Two  studies published in July and August document the worsening trends including:  

And along with the annual death toll, scientists worry that a drug resistent pathogen could trigger the next pandemic.

Meanwhile a long-delayed ministerial meeting to follow up on the commitments made in 2024 is now finally scheduled for 6-8 December in Abuja, Nigeria. Ahead of the December event, a multistakeholder meeting including civil society, academia and private sector, as well as governments, will meet in Rome 16-18 November, during World Antimicrobial Awareness Week. 

Calling on governments to invest more in AMR 

All-age rate of deaths attributable to bacterial antimicrobial resistance by
region, 2019, as published in The Lancet’s 2022 estimate of 1.27 million such deaths annually.

A draft “Abuja Compact on Antimicrobial Resistance” prepared for the December ministerial calls on governments to recommit to the goals of the 2024 Declaration, and include more AMR spending in routine government planning and budgets. It notes that only about 10% of national AMR action plans are adequately financed.

Governments would also be asked to strengthen national surveillance of antimicrobial resistance and antimicrobial consumption – which includes antibiotics, but also anti-parasitic and anti-viral agents. 

And national systems should step up routine reporting of such data to the World Health Organization (WHO), the Food and Agriculture Organization (FAO) and the World Organization of Animal Health (WOAH). 

Governments are also asked to step up commitments to infection prevention; access to clean water and sanitation; improved use of diagnostics and appropriate antibiotics; as well as more investments in R&D, as well as regional manufacturing of health products. 

The 2024 AMR commitments included improved access to clean water, sanitation and hygiene (WASH) critical to blunting the proliferation of drug-resistant pathogens.

Finance is another overarching theme of the draft. The Compact calls for greater involvement by finance ministries and asks the World Bank, regional development banks and other funders to consider AMR in grants and lending. That reflects a problem repeatedly raised by countries and civil society groups that many governments have adopted AMR plans without allocating enough money to carry them out.

“There’s been a lack of investment in actual National Action Plans. We need to dramatically step this up if we want to effectively combat AMR,” says Katherine Urbáez, founder and executive director of the Geneva-based Health Diplomacy Alliance, which as been a leading civil society actor on AMR.

“The December meeting is a chance to reaffirm our commitments, and accelerate action. The Rome meeting will also provide an important platform for engaging civil society, academia and the private sector.” 

Ambitious 2024 commitments but poor followup  

Plans to fight AMR have been made but not implemented. Seen here, a mapping of NAP implementation.

In the 2024 UN GA declaration, all UN member states committed to creating national action plans (NAPs) to fight AMR  but few have actually invested money into them. 

According to the latest WHO data from 2023, while 178 countries had developed and endorsed AMR NAPs, only about 11% were in fact implementing them. And anecdotal observations indicate little has improved since, says Urbaez. “We need strong engagement from Governments to participate in this Abuja meeting – and so far we haven’t seen enough of that,” Urbáez says. “Now, Abuja is the moment to focus on delivering them: tracing each commitment to measurable implementation, so that governments and partners can see where to act next and what is politically feasible.”  

Progress in Geneva – WHO AMR action plan 

The 79th session of the WHA in Geneva in May 2027 adopted an AMR action plan after over a year of delays.

This year has seen some progress already in Geneva. In May, the World Health Assembly adopted a Global Action Plan on AMR (2026-2036) after over a year of delays due to developing and developed country wrangling over language around technology transfer. 

The plan strengthens the ‘One Health’ framework for combatting AMR across human, animal, plant and environmental health sectors – setting out a road map for Health Ministries to act more assertively, with WHO support.  And it highlights member state commitments to themes of UN Declaration including prevention, equitable access to antimicrobials alongside responsible use; stronger surveillance and financial measures. See related story: 

Infection Prevention and Control Falters Post-Pandemic – Increasing AMR Risks 

Civil society advances new ‘check the box’ initiative 

On the sidelines of the World Health Assembly, and in fora since, civil society organizations have become active in tracking countries commitments to AMR plans and programmes and their follow-through – including through a new ‘Check the box’ initiative, launched by HDA.

“Check the Box is not about naming and shaming,’ Urbáez said at a WHA side event where the initiative was launched: ‘The aim is to link the dots between promise and delivery so governments and partners can identify what is missing and act.” 

(L-R) Katherine Urbáez, HDA and Ntuli Angyelile Kapologwe, East Central and Southern Africa Health Community at May ‘Check the Box’ event.

At the event, , the AMR-Health Security Equation, experts in AMR and senior government exchanged views on why high-level commitments are so often diluted as they move into national planning and delivery.

Money is a key problem, pointed out Ntuli Angyelile Kapologwe, Director General of the East Central and Southern Africa Health Community. Laboratories, pathogen surveillance and water and sanitation systems all require sustained expenditure, yet budgeting for such costs is far removed from the lofty statements issued in international meetings, “Global commitments must be translated into national measures,” he said. 

Silvia Bertagnolio, WHO.

“A national action plan means changing practices around procurement, prescribing, laboratory capacity, infection prevention, workforce planning and access to treatment,” added WHO’s Silvia Bertagnolio.

For countries sharing borders and markets, national plans therefore depend in part on regional surveillance and cooperation, other health officials pointed out. And resistant organisms not only cross those borders through trade, but they move through people, food systems, agriculture and water ecosystems, as well – while responsibility for these areas is divided across ministries and agencies. 

(L-R) Fernando Boyd Galindo, Panama; Gina Estrella Ramia, Dominican Republic; José Renán De León Cáceres, SE-COMISCA.

“Measures must have an institutional owner; that institution must have authority, staff and financing; and indicators, data sources and a reporting timetable,” said Gina Estrella Ramia, vice-minister of Environmental Health in the Dominican Republic. She stressed that finance ministries need to be involved in AMR planning from the outset. 

Reinforcing a ‘One Health’ approach

Lab technician trains in standardized and harmonized surveillance methods for antimicrobial resistance (AMR) in food animals in Southeast Asia.

Responding to that need for a holistic approach, ‘Check the Box’ tracks country follow-up on recommendations issued all four global agencies that make up the One Health Quadrapartite, founded in 2022 to coordinate work against AMR.

They include not only WHO, but also the UN Environment Programme (UNEP), the Food and Agriculture Organization (FAO) and the World Organisation for Animal Health (WOAH).  

“The Quadripartite created important technical  and scientific foundations. Our role is to help sustain the political attention and coordination needed to turn those foundations into measurable results,” said Urbáez. 

Tracking systems incomplete 

Resistent Infections by Region

Each organization coordinates and reports on core components of the global response – but tracking systems remain fragmented and incomplete. 

For instance, WHO’s GLASS data base is supposed to follow trends in appropriate antibiotic use, and resistant infections recorded by health systems.  However around 42% of countries don’t report to WHO at all. And in the case of others, reporting is limited. 

That limits WHO’s ability to provide accurate global and regional tracking of actual trends in resistant infections. The slack in missing data is picked up by modelled estimates of the global burden of deaths and disease, undertaken by the Institute of Health Metrics and Evaluation in collaboration with actors such as Wellcome Trust and the University of Oxford.

In the food and agriculture sector, FAO’s InFARM collects data on antimicrobial use in crop and animal production – but most of that data is not even publicly available.  This, despite the fact that the lion’s share of antibiotics, in terms of volumes, are used in agriculture and not humans. See related story:

Breeding Superbugs – Veterinary Drugs, More than Human Ones, Drive AMR 

On a more positive note, however, the World Organization for Animal Health (WOAH) has begun reporting on antimicrobial use on animal more transparently. It’s new ANIMUSE database follows trends in nearly 120 countries, by region and by leading antimicrobial agents. This provides valuable data to countries aiming to reduce inappropriate use. 

New WOAH data base tracking antimicrobial quantities used in animal production by reegion reveals the greatest excesses are in Asia and the Americas.

Budget strapped UN agencies – a weaker wheel of engagement ?  

The efforts of the Quadriparte, as well as the broader constellation of global and regional stakeholders, however, also face new challenges from the wave of budget cuts hitting global health  – and most notably, WHO’s AMR programme. 

WHO’s AMR team has been “emaciated” one insider notes – with a full-sized department now shrunk to a unit of just 13 people with no acting director.

The high-profile former WHO Assistant Director General Hanan Balkhy, who once led the AMR effort, left to become Director of WHO’s Eastern Mediterranean Region, and is now on leave from that position as a candidate to become the next WHO Director General. 

Pipeline of new antibiotics and preventative therapies 

Testing for antimicrobial resistance among a variety of different bacterial strains.

Another gap is in the arena of prevention. An October policy brief by the BEAM Alliance, an innovation hub for European biotech companies, cites one recent study showing that some 83% of adults with viral respiratory infections are still wrongly prescribed antibiotics, even though antibiotics do not treat viral infections.

But beyond the classic approaches of better diagnosis, prevention of common, chronic infections should also be given more attention in AMR R&D, argued Christian Terreaux, Public Affairs Director at OM Pharma, a BEAM Alliance member.

Christian Terreaux, OM Pharma and BEAM Alliance

This should include more investment in vaccines and immunotherapies that can help reduce recurrent infections and the resulting need for antibiotics, he said, citing research estimating that every €1 invested in prevention returns about €3 in economic benefits.

“AMR policy on infection prevention needs to consider a broader spectrum of preventive options beyond the important hygiene and sanitation measures and vaccination programs,” argued  Terreaux. And that should include “leveraging already existing options to reinforce the immune system, as well as stronger incentives to promote development of novel strategies.” 

Image Credits: WHO/Quinn Mattingly, The Lancet, L Pezzoli/ WHO, HDA , WHO/X, Health Policy Watch , Fletcher/Health Policy Watch , USAID Asia/Flickr, WHO GLASS, 2025, WOAH/ANIMUSE, DFID – UK Department for International Development.

The destruction of farmland, forests, wilderness and waterways is still outpacing restoration efforts worldwide, which lag far behind 2030 goals. Annual spending on restoration would need to rise more than fourfold, from $64 billion in 2022 to $296 billion by 2030, according to a report released in Yerevan, Armenia, a day before the close of the UN biodiversity summit, COP17.

Countries have launched nature restoration efforts for some 252 million hectares (623 million acres) of degraded forests, farmland, wetlands and coastline since 1966, an area larger than Algeria. But the pace of restoration work would have to roughly triple in the next four years for the world to meet its 2030 goal for reviving nature, according to a new United Nations report.

The assessment, published Thursday, is the first to tally restoration efforts across the world’s land masses, freshwater systems and oceans. It was released in Yerevan, Armenia, a day before the UN biodiversity summit there, COP17, closes amid divisions over who should pay to protect nature and how fast to cut the subsidies that fuel its destruction.

“Today, we are witnessing the makings of one of the largest movements for nature in recorded history,” said Inger Andersen, executive director of the UN Environment Programme (UNEP), in a statement released with the report. “Yet, at the halfway point of the UN Decade on Ecosystem Restoration, we are still not restoring nature at the scale or speed required. By 2030, we must turn inspiring initiatives into systemwide action.”

Geographical distribution of documented country-level restoration commitments.

The report, by the UN Environment Programme, the Food and Agriculture Organization (FAO) and the secretariat of the Convention on Biological Diversity (CBD), measures progress against Target 2 of the 2022 Kunming-Montreal Global Biodiversity Framework, which commits countries to having at least 30% of degraded ecosystems under effective restoration by 2030.

The authors set that benchmark at about 738 million hectares, leaving the area currently under restoration at 34% of the 2022 target and about a quarter of the roughly 1 billion hectares countries have pledged in their national plans.

Meanwhile, land is still being degraded faster than it is being restored, according to the latest available data. Between 2015 and 2019, at least 100 million hectares of healthy, productive land was degraded every year, UN Desertification Convention figures cited in the report show.

“Financing the destruction of nature with 30 dollars against every dollar spent restoring it,” said Astrid Schomaker, the CBD’s executive secretary, as the summit entered its final week on Monday, “is like paying 30 people to tear down your house for every one hired to rebuild it.”

Restoration commitments by region (in Mha) and relative to total regional land area (%).

The UN climate summit, COP31, opens in Antalya, Turkey, next month. Degraded peatlands, which hold up to a third of the world’s soil carbon, produce about 4% of global human-caused greenhouse gas emissions, yet only around 15% of countries include them in their national climate plans.

“Restoration is woven very closely into nationally determined commitments,” said Doreen Robinson, deputy director of UNEP’s Ecosystems Division, at a briefing for journalists before the launch, “and so this report will be just as useful for that COP as it is for this COP.”

“We are making progress, but we are still in a net deficit here, and we need more investment,” Robinson said when asked whether the world was gaining ground overall. “We’re on the pathway. If we continue with our restoration investments and the other investments we’re talking about here at COP, we could reverse course for nature, but it is still a net deficit for nature.”

Seas and freshwater systems left behind

Marine and coastal ecosystems have 5.7 million hectares under restoration worldwide, 23% of what the 2030 target requires, according to the UN report.

Almost all of the documented progress is on land surfaces, where 232 million hectares are under restoration, about half of the 2030 target for terrestrial ecosystems. In contrast, freshwater ecosystems have 11 million hectares under restoration across 62 countries, a mere 4.5% of their target. Marine and coastal restoration efforts cover another 5.7 million hectares in 46 countries, or 23% of their target.

“Reported restoration lags far behind ambition in both freshwater (inland water) and marine and coastal ecosystems,” the report states, “yet these ecosystems are degrading at the highest rates, highlighting the critical need for accelerated implementation and improved data availability and reporting.”

Wetlands are disappearing three times faster than forests, according to research cited in the report. At sea, the 2024-2025 coral bleaching event was the most extensive on record, hitting about 84% of the world’s reef areas, which are critical breeding grounds for fish and other sea life.

“No ecosystem is sufficiently funded. All ecosystems are under threat, but we do know, and you’ll see in the report, that some lag behind others,” Robinson said. “In particular, freshwater and dryland ecosystems are lagging behind.”

China accounts for half the world’s restoration areas

Proportion of degraded land over total land area, 2019.

China reports 127.4 million hectares under restoration, roughly half the global total and 54% of all documented restoration on land. Mongolia and Kazakhstan follow with 12.2 million and 8.1 million hectares, respectively. Asia as a whole accounts for more than three-quarters of the restoration documented across land, seas and freshwater worldwide.

Listing an area as “under restoration” means only that the work has been documented, the report stresses, and “does not necessarily demonstrate that the ecosystem has recovered or that the activity meets the full requirements for effective restoration.”

The CBD’s own progress review, which drew on fewer national reports, records restoration work on only 193 million hectares, against 252 million in the joint report.

“Half of the countries that reported to the CBD in their seventh national report did not include any quantitative data on restoration, and these countries cover about 3 billion hectares of land,” said Yelena Finegold, who leads ecosystem restoration monitoring at FAO and was the report’s lead author. “So we’re also not capturing all of the incredible efforts that are happening on the ground.”

A fourfold finance gap

Underlying causes and indirect and direct drivers of biodiversity loss and nature’s decline.

Annual spending on restoration would need to rise more than fourfold, from $64 billion in 2022 to $296 billion by 2030, according to UNEP estimates first published in 2024 and cited again in the report.

Public budgets supplied 73% of the money, and five countries, among them China and the United States, accounted for 76% of public spending in the farming, forestry and fisheries programs behind most of it.

“Restoration-targeted official development finance reached only USD 1.2 billion,” the report says, “a fraction of what is needed by developing countries.”

Private investors added about $17 billion, more than two-thirds of it through biodiversity offsets and credits required under compliance schemes. Governments, meanwhile, spent an estimated $2.4 trillion on environmentally harmful subsidies in 2023. Total finance damaging nature reached $7.3 trillion, more than 30 times the amount invested in nature-based solutions.

“Mobilizing additional restoration finance will have limited effect,” the authors write, “if much larger public and private financial flows continue to drive ecosystem degradation.”

“We’re not talking about billions here,” said Salman Hussain, head of UNEP’s Economics of Nature Unit, “but 2.4 trillion in environmentally harmful subsidies.”

Finance fight in Yerevan

COP17 underway in Yerevan, Armenia. The summit wraps up on Friday as climate negotiators prepare to shift focus to COP31 in Türkiye next month.

COP17 is holding the first global review of the Kunming-Montreal framework. In Friday’s closing session, governments are due to adopt a plan for the years 2026-2030, known as the Yerevan Pathway.

Under the framework’s Target 18, countries also agreed to cut harmful subsidies by at least $500 billion a year by 2030. When the UN’s State of Biodiversity Action report was launched before the summit, the CBD said “far fewer” countries had committed to reducing harmful subsidies, and that targets on harmful incentives were “among those furthest behind.” Governments in Yerevan were still divided this week over language on reducing or phasing out such incentives, including agricultural subsidies, the CBD said Monday.

Negotiators remain split over a European Union push to widen the list of countries expected to contribute to international biodiversity finance to include emerging economies such as China and affluent Gulf states. The Arab group told the opening plenary it “rejects any attempt” to expand the list, Climate Home News reported.

“It’s been 20 years since that list was added,” Christopher O’Sullivan, Ireland’s nature minister, whose country holds the EU’s rotating presidency, told reporters. “Times have changed and there are new realities.”

Image Credits: Eutah Mizushima.

As temperatures rise, heatwaves, floods and other climate emergencies are increasing. Nearly one million Somalians were affected by a flood in 2020 (above).

A decade after the Paris Agreement took effect, climate-related heat, drought, floods, disease and dirty air are killing millions. The authors of a major annual report want the World Health Organization (WHO) to classify the crisis as a health emergency.

Climate change has become a global health emergency that needs a new WHO instrument to coordinate the global response, the Lancet Countdown on health and climate change said on Wednesday, in a new report that finds a warming world’s toll on health is rapidly expanding.

Heat caused by human-driven warming killed nearly three million people between 2016 and 2023; droughts and extreme rainfall spread faster, conditions for dengue and Vibrio bacteria reached new highs, and air pollution from burning fossil fuels is killing 2.78 million people a year, according to the Countdown’s 10th annual report, published in The Lancet.

“Because of the rapidly growing threats over the past decade, climate change has become a global health emergency,” the report asserts.

“Addressing it requires urgent course-correction to deliver coordinated and evidence-based action across borders to protect health and survival.”

Huge fossil fuel subsidies continue

As heatwaves turn to “heatstorms“, scorching forests, oceans and pavements around the globe, governments poured a net $6.2 trillion into direct fossil fuel subsidies from 2016 to 2024, the report found.

In 2024, 10 countries spent more propping up oil, gas and coal than on their health systems. Counting the unpaid costs of pollution and climate damage, the IMF puts total fossil fuel subsidies at about $7.4 trillion in 2024 alone, $6.7 trillion of it indirect – nearly 25 times the $300 billion a year that wealthy nations agreed in 2024 to deliver to developing countries for climate action by 2035.

The authors want WHO to develop a new instrument that formally recognises climate change as a global health emergency. Until one exists, they want existing tools, including the International Health Regulations (IHR), to be used to grade and respond to climate-driven health crises.

Heatwaves are becoming heat storms that are killing more people.

The WHO’s highest-level alarm, a public health emergency of international concern (PHEIC), has been used declared for COVID-19 and Ebola. However, it and other existing WHO instruments are designed for short outbreaks, not crises like climate change that run for decades.

“The problem currently with the public health emergency of international concern … is that it’s very tailored to short-lived emergencies and especially to emergencies that can cross borders like infectious diseases,” Marina Romanello, executive director of the Lancet Countdown, based at University College London, told a media briefing. 

The Countdown wants an emergency response “that is fit for purpose, not only for emergencies like infectious diseases but also for catastrophes like those caused by climate change … so that we’re not responding to emergency after emergency”, Romanello added.

“A decade after the Paris Agreement, our findings are unambiguous: the health harms of climate change are growing faster than the world’s response to them, and in many cases even accelerating,” said Romanello.

Absence of political will

“What’s missing is not evidence, but the political will to act on it,” said Helen Clark, a former Prime Minister of New Zealand, who chairs the Countdown’s board. “Governments must double down on their climate action commitments and rebuild momentum for international co-operation.”

The findings land as the UN biodiversity summit, COP17, enters its final days in Yerevan, Armenia, with a first global stocktake of nature restoration by UN agencies due on Thursday. In two weeks, governments meet in Antalya, Türkiye, for the annual UN climate summit, COP31.

Last week, the UN Environment Programme found that the chance to hold warming to 1.5°C higher than pre-industrial temperatures without significant overshoot has passed. Current policies put the world on track for about a 2.8°C increase. Keeping the overshoot to 1.8°C in the coming decades would require emissions to nearly halve within 10 years.

The Countdown’s targets for the coming decade include an immediate ban on new fossil fuel exploration, an end to coal power by 2035, health early warning systems in every country by the end of 2027, a global climate and health data commons, and grant-based finance to enable countries to adapt to climate without taking on more debt.

Meeting those targets, the authors concluded, is “no longer just the greatest public health opportunity of the century”. It “may be the only hope for a safe future.”

“The evidence is undeniable,” said WHO Director-General Tedros Adhanom Ghebreyesus in a media release. “Climate change is one of the greatest threats to health facing humanity.”

Deadlier heat

Pregnant women, newborns and the elderly are worst affected by heat.

Heat was linked to a record 710,000 deaths in 2023, and almost three-quarters (71.5%) were caused by climate change – the first time the Countdown has attributed heat deaths directly to human-driven warming.

Between 2016 and 2023, heat was linked to an average of 540,800 deaths a year, up 36% on the decade before. Climate change caused 68.4% of them, up from 55% in the decade before the Paris Agreement took effect.

As global warming hurtles towards the 1.5°C target set by the Paris Agreement, the climate-driven toll on health has grown by about 15,600 deaths each year on average. Newborns, pregnant women and older people bear the brunt, the report says. Earlier this month,  UN climate chief Simon Stiell described heat’s threat to mothers and newborns as “a new fault line in the global climate crisis”.

“Heat-related mortality is just the tip of the iceberg,” Romanello told reporters ahead of the launch. “We know that behind every heat-related death, there’s a huge burden of disease, a huge increase in pressure on our health systems and healthcare.”

Heat erased 573 billion potential work hours in 2025 and $1.07 trillion in income, the third straight year above $1 trillion, according to the Countdown. Countries ranked lowest on the UN’s Human Development Index (HDI), which combines measures of health, education and income, lost the equivalent of 5% of their economic output, against 0.5% in the highest-ranked countries, with farm work accounting for 78% of their losses.

Meanwhile, the share of the world’s land in extreme drought grew eight times faster since 2016 than in the decade before, the report found, while the area hit by very extreme rainfall grew 57% faster.

Heatwaves and droughts pushed 127.9 million more people into moderate or severe food insecurity in 2024 than if their frequency had stayed at 1981–2010 levels.

Unhealthy diets contributed to 10.5 million deaths in 2023, up from 9.5 million in 2016, with red and processed meat and dairy linked to 1.6 million of them.

“In Southeast Asia, we’re seeing lost productivity due to heat being the equivalent of 3.9% of their GDP,” said Ollie Jay of the University of Sydney, who co-chairs the Countdown’s working group on health hazards.

“In an era where we’re so obsessed and preoccupied with growing the economy, this is a clear impact of climate change that is having a direct impact on the economic output of particular countries.”

Heat is having a devastating impact on crops, particularly in countries that can least afford it.

Diseases on the move

Higher temperatures have also expanded the reach of diseases. For example, dengue cases hit a record 14.4 million in 2024 as the climate for its transmission by the Aedes aegypti mosquito, rose 125% faster than in the decade before.

Warming seas are spreading Vibrio bacteria too. Estimated cases of vibriosis, an infection picked up from warm coastal water and seafood, reached a record 738,000 in 2025, and have climbed by about 24,700 a year since 2016, up from 3,600 a year in the decade before.

Malaria and West Nile virus are also moving into new places. In Africa’s highlands, the climate suitability for the deadliest malaria parasite, P. falciparum, rose almost 13%, while the suitability for West Nile virus climbed 12% in Europe. Some tropical areas are now too hot for both, but more suitable for dengue, the report said.

Dengue Chikungunya Zika
Climate change is expanding the areas where disease-carrying mosquitoes can operate.

Health systems left exposed

By 2025, 71% of WHO member states still had no plan to adapt their health systems to climate change, and 76% had not assessed their vulnerability since 2020, the report found.

Only 34.6% of the lowest-ranked countries on the HDI reported a strong ability to detect, prepare for and respond to health emergencies in 2025, in comparison to 80.6% of the highest-ranked countries, according to their own reports to WHO. 

That capacity matters more as climate change makes such emergencies more frequent and severe, the report said.

Where climate-informed health early warning systems exist, now in 75 countries, the number of people affected by storms and floods is rising more slowly.

Developing countries have costed their health adaptation needs at $3.3 billion a year. However, donors committed $1.1 billion in 2024.

“We’re not nearly providing enough finance to support countries in a just transition to support adaptation and to protect the health of people in every country,” said Romanello.

Aid from the 17 largest donors, which pays for health, development and humanitarian work in low- and middle-income countries, is projected to fall by more than $50 billion (about 25%) between 2023 and 2026, led by the withdrawal by the United States. Several donors have tied the cuts to higher defence spending, the report found.

“In the context of climate change, where adaptation finance is already described as ‘grossly insufficient’ relative to needs, further reductions risk widening the gap between rising risks and available support,” the report said, “leaving people increasingly unprotected amid rising climate hazards.”

That gap will shape the fight over health finance at COP31 in Antalya.

Meanwhile, the share of countries linking climate and health in their speeches at the annual General Debate of the UN General Assembly fell from 65.9% in 2021 to 26.3% in 2025. Climate plans from the most developed countries are consistently the least likely to mention health, the report found.

“Climate change, and particularly climate change and health as an issue, is being crowded out by the fact that we’ve got greater global instability,” said Niheer Dasandi, a professor at the University of Birmingham who leads the Countdown’s work on political engagement.

“As conflicts increase, as tensions rise, we see much more of that international attention diverted towards those issues.”

The tightening grip of fossil fuels

Vehicles are the biggest source of pollution in Delhi, one of the most polluted cities in the world.

Air pollution from burning fossil fuels killed 2.78 million people in 2023, about the same toll as in 2016. Deaths fell in 75 of the 140 countries assessed, led by China, saving 323,000 lives a year, but rising deaths elsewhere cancelled out the gain. 

In countries in the index’s middle tier, such as India, the death rate climbed 20.7%. Smoke from cooking and heating with wood, coal and other solid fuels killed another two million people in their homes.

International development lenders committed $4.7 billion in 2024 to projects aimed at cutting air pollution, less than 1% of all development finance, according to a Clean Air Fund report.

The strategies of the world’s 100 largest oil and gas companies put them on track to produce 150% more in 2040 than their share under a 1.5°C pathway, up from 138% a year earlier, the report found. 

The report also traces a decades-long disinformation and lobbying campaign by major oil companies, which had accurately projected dangerous warming by the early 1980s. It points to proposals from public health researchers and the UN to restrict fossil fuel advertising in the way tobacco ads were restricted.

“The tactics are very well described, and they include the manufacture of doubt,” Diarmid Campbell-Lendrum, who leads WHO’s climate change and health work, said on Monday at a separate webinar launching a paper on climate disinformation by a WHO civil society working group.

“The distraction onto other issues, trying to point the finger of blame at anything but tobacco consumption… are exactly the same tactics, and even in some cases the same players, which are now spreading climate disinformation.”

 

Image Credits: UNICEF, AP, WMO, International Confederation of Midwives, WMO, James Gathany/ PHIL, CDC, Public Domain, Chetan Bhattacharji.

Who will steer the World Health Organization through its next chapter? Explore Health Policy Watch’s daily series examining the platforms, records, and institutional hurdles facing each contender for WHO Director-General, continuing today with Gevorg Tamamyan. Access all candidate profiles on our dedicated election site.

Tamamyan’s campaign challenges the World Health Assembly to re-anchor global health in a shared commitment where geography never decides who lives.
Tamamyan’s campaign challenges the World Health Assembly to re-anchor global health in a shared commitment where geography never decides who lives.

Dr Gevorg Tamamyan, an Armenian paediatric oncologist and professor at Yerevan State Medical University, has joined the race for WHO Director-General under a unique cross-regional nomination by the Republic of Botswana. Entering a competitive field of seven candidates as a clinician-academic and the youngest contender (born in 1987), his candidacy introduces a distinct frontline perspective to the 2027-2032 election.

His career spans clinical practice, national health system consolidation, global diplomacy, and humanitarian protection in conflict zones, and Tamamyan anchors his bid in a central thesis: “humanity first” and the principle that “geography must not decide who lives.” In response to the acute financial contraction, geopolitical rifts, administrative bloat as well as aid models that perpetuate dependency, he envisions a WHO that empowers countries, evaluates performance by measurable population health outcomes, communicates transparently, and restores institutional trust.

However, his central challenge will be convincing member states that a clinician-academic without sovereign ministry or UN executive experience can govern the world’s premier health agency. While his sweeping platform offers bold prescriptions for an overextended organisation, his wide-ranging proposals could conflict with operational command of dense UN statutory frameworks, civil service rules, and entrenched national interests.

From clinical execution to global reform

Calling for patient-centred WHO reform, Gevorg Tamamyan (second left) presents his vision in Berlin alongside fellow candidates María Neira, Hanan Al Kuwari, and Budi Sadikin.
Calling for patient-centred WHO reform, Gevorg Tamamyan (second left) presents his vision in Berlin alongside fellow candidates María Neira, Hanan Al Kuwari, Budi Sadikin, and moderator Björn Kümmel.

Translating his central campaign thesis into operational pillars – articulated in response to a candidate query by Health Policy Watch, across his social media communications and at the World Health Summit (WHS) in Berlin – his platform rests on four core commitments:

  1. Patient-centred governance and delivery over process: Under his “WHO for U” vision (representing the individual, unity, and universal health), Tamamyan argues that institutional trust has become dangerously fragile. He asserts that WHO must adopt the patient as its non-negotiable “North Star,” measuring success by frontline health outcomes rather than administrative activity. While member states own health delivery, he posits that WHO’s normative impact can be operationally traced through stronger national plans, disease registries, access to essential medicines, standards of care, and targeted technical support.
  2. Health sovereignty and the Accra Reset: Aligning directly with the principles of the Accra Reset and his nominating state, Botswana, Tamamyan advocates for country ownership over external aid dependency. He supports establishing local biomanufacturing, regional laboratory networks, and costed national health strategies across the Global South.
  3. Transparency, accountability, and refocused scaling: Tamamyan advocates testing interventions against real-world evidence, openly acknowledging when strategies fail, and reducing unfunded mandates. Responding to Health Policy Watch regarding which specific mandates WHO should scale back, he emphasised that scaling back cannot be a unilateral decision by the Director-General, but must be conducted transparently in partnership with member states to restore trust and unlock flexible, unearmarked financing.
  4. Workforce modernisation and operational HR reform: Addressing WHO’s 154-day recruitment average and demographic gap (under 1% of staff under 30), Tamamyan outlines a targeted HR overhaul. His “No Empty Desks” policy enforces a 60-day hiring cap, reclassifies interim roles as open vacancies, and mandates quarterly public tracking. Concurrently, drawing on his trajectory leading a national department at 31, he advocates giving young talent real decision-making authority and governance seats.

To translate these principles into immediate momentum, Tamamyan outlined a focused first 100 days roadmap in Berlin. His priorities centre on empowering WHO’s internal workforce and launching direct diplomatic outreach to non-participating nations – specifically visiting the United States and Argentina to listen, address concerns, and encourage their full return to the organisation.

From paediatric oncology to health system building

Main building of Yerevan State Medical University where Tamamyan trained and serves as Professor and Department Chair.
Main building of Yerevan State Medical University where Tamamyan trained and serves as professor.

By anchoring global governance reform in clinical urgency, empirical rigour, and fresh system-building, his policy roadmap directly mirrors his own professional trajectory, moving from paediatric oncology wards and hospital consolidation in Armenia to international health networks and crisis management in active conflict zones.

After earning his MD, PhD, and DSc degrees from Yerevan State Medical University (YSMU) alongside an MSc in Advanced Oncology from the University of Ulm, he completed postdoctoral research and fellowships across leading global institutions, including UT MD Anderson Cancer Center, St. Anna Children’s Hospital in Vienna, EORTC in Brussels, and Dana-Farber/Boston Children’s Cancer Center.

At the age of 31, Tamamyan translated this academic preparation into national-scale execution by leading the consolidation of Armenia’s fragmented paediatric cancer services into the unified Pediatric Cancer and Blood Disorders Center, serving as its head from 2019 to 2024. Under his direction, the centre introduced standardised multidisciplinary care protocols and established Armenia’s first dedicated paediatric oncology fellowship programme, with reported survival rates for childhood malignancies rising to approximately 80%.

Extending his system-building internationally, Tamamyan leads multi-country technical cooperation across resource-constrained settings. He serves as President of the International Society of Pediatric Oncology Asia Continental Branch (SIOP Asia) and President of Pediatric Oncology East and Mediterranean (POEM) Group, a network that encompasses 110 cancer centres across 28 countries.

Alongside his academic and clinical responsibilities, he co-founded the City of Smile Charitable Foundation to guarantee financial coverage for paediatric cancer treatment. To expand local clinical trials, he established the Armenian-based Immune Oncology Research Institute. He also co-founded OncoDaily, a global oncology media platform.

Non-aligned bid for global health sovereignty

Tamamyan advocates robust local production and regional testing hubs to reduce dependence on external health supply chains.
Tamamyan advocates robust local production and regional testing hubs to reduce dependence on external health supply chains.

A surprise candidate, Tamamyan’s nomination introduces an unconventional geopolitical manoeuvre: an Armenian clinician-academic nominated by the southern African nation of Botswana. He leverages his positioning as a complete outsider to WHO headquarters and national ministries to differentiate his bid from his competitors.

Reinforcing this platform, he asserts that WHO must maintain a direct physical presence in conflict zones to enforce the protection of health facilities and workers, defining WHO neutrality as active engagement with all combatant parties. He advocates for real-time mapping of vulnerable chronic care facilities before conflicts escalate and establishing protected health corridors to maintain the flow of cancer therapeutics, dialysis, and emergency evacuations.

Facing WHO’s budget contraction and recent external audit scrutiny over the WHO Foundation’s low transfer rates and heavy earmarking, Tamamyan proposes reforming the Foundation into a mass public-giving instrument. Citing the Foundation’s reported $215 million mobilised across its first five years, he envisions cultivating millions of regular individual donors to generate flexible, unearmarked support for WHO’s core budget – backed by full transparency regarding administration costs, donor acquisition, and net transfers.

Finally, addressing the declared retreat of the United States and Argentina from the WHO, Tamamyan leverages his non-aligned positioning to spearhead diplomatic outreach aimed at bringing both countries back into full WHO participation. Choosing Boston as the first stop on his campaign tour, he argues that an outsider unencumbered by regional bloc politics can restore fractured trust by listening, eliminating administrative bloat, and demonstrating that WHO membership delivers undeniable frontline value.

Political challenges for a diplomatic outsider

Tamamyan’s non-aligned bid faces complex geopolitical dynamics across Member States accustomed to traditional regional caucuses and political compromises.
Tamamyan’s non-aligned bid faces complex geopolitical dynamics across member states accustomed to traditional regional caucuses and political compromises.

Tamamyan’s non-aligned bid faces complex geopolitical dynamics across member states accustomed to traditional regional voting blocs. His nomination by Botswana challenges African Union caucuses that typically seek pan-African consensus, while his Armenian nationality adds a third European Region contender alongside Dr Hans Kluge (Belgium) and Dr María Neira (Spain).

Responding to this scrutiny, Tamamyan asserts that “health is not a bloc,” arguing that Botswana’s sponsorship reflects shared Global South alignment – specifically around country ownership, local biomanufacturing, and the Accra Reset – rather than geographic origin.

However, his lack of ministry- or UN-scale governance experience presents a central hurdle for a candidate seeking to manage a multi-billion-dollar international bureaucracy. Pushing back against this concern, Tamamyan frames the Director-General role as a system-level orchestrator: “I have never tried to be the smartest person in the room. My mission has always been to surround myself with the smartest people, empower them… and hold them accountable,” he maintains.

Finally, his clinician-first instinct exposes potential vulnerabilities regarding institutional discipline. During the World Health Summit in Berlin, Tamamyan asserted that WHO should prioritise frontline responsiveness over rigid jurisdictional limits: “We should be the place where anyone can call, can say, ‘Okay, I have this problem,’ even if it is not within our mandate, but we are able to help”. While demonstrating an agile, patient-centred ethos, this willingness to step outside formal mandates could clash with member state demands for strict focus, fiscal restraint, and an end to organisational mission creep.

Test case for transregional outsider reform

Grounding his campaign in an unconventional cross-regional nomination by Botswana, Tamamyan rejects traditional regional bloc politics in favour of his “WHO for U” platform. Setting out his core rationale for organisational reform – that “architecture begins with who we are building for” – he argues that a WHO built for people must lead rather than compete.

His diagnostic of WHO’s vulnerabilities – sluggish recruitment, unfunded mandates, and operational drag – strikes a chord across capitals eager for change.

Yet the critical friction running through his candidacy remains the divide between expansive frontline vision and granular institutional execution. In Geneva, promises of unbureaucratic overhaul inevitably collide with rigid civil service statutes, binding legal frameworks, and the fiscal discipline demanded by member states.

Ultimately, Member States face a fundamental choice between seasoned political executives and an outsider offering bold, unvetted ambition.

Profiles will be updated as the campaign progresses, stay tuned on the microsite.

Image Credits: Gevorg Tamamyan via LinkedIn , Felix Sassmannshausen/HPW, Diana2198 via Wikipedia, Yuri Shkoda via Canva, WHO/Antoine Tardy .

Global Fund
The Global Fund has electronic displays in Times Square in New York City this week.

Former Global Fund executive director Mark Dybul returns to the helm in Geneva, facing an unprecedented $5.32 billion funding gap, fraught domestic transitions, and mounting demands to overhaul the global health architecture. While experts welcome his track record, balancing transatlantic rivalries with rising country sovereignty will demand delicate diplomacy and an updated playbook.

Incoming Global Fund Executive Director Mark Dybul.
Incoming Global Fund executive director Mark Dybul.

The board of the Global Fund to Fight AIDS, Tuberculosis and Malaria appointed Dr Mark Dybul as its next executive director on Wednesday during its 56th board Meeting. Dybul, who previously led the fund from 2013 to 2017, will take office in early 2027 for a four-year term following the end of Peter Sands’ tenure.

The appointment was largely expected and concludes an intensive search process launched in February. Dybul, an American global health veteran who sources say enjoys strong backing from the current US administration, was selected over four other finalists announced in late September. These were Richard Hatchett, outgoing CEO of the Coalition for Epidemic Preparedness Innovations (CEPI); Save the Children US head Janti Soeripto; Novartis executive Lutz Hegemann; and Tanzanian diplomat and former UN Assistant Secretary-General Joyce Msuya.

Dybul inherits a partnership confronting an unprecedented $5.32 billion funding gap after its Eighth Replenishment secured $12.68 billion against an $18 billion target, according to updated figures confirmed by the Global Fund Secretariat in response to a query by Health Policy Watch.

“Mark brings exceptional experience, deep commitment and a proven track record of delivering results in global health,” said board chair Lady Roslyn Morauta. “At a time of profound change in global health, his vision and determination will be invaluable as we adapt to new realities.”

To manage the deficit, the board approved $10.78 billion in core country allocations for the 2026-2028 allocation period (for 2027-2029 implementation) alongside an initial $260 million for catalytic investments, leaving the incoming chief to steer implementation through these cuts while safeguarding frontline services.

Global Fund strategy and country self-reliance

The Global Health Campus in Geneva, HQ of the Global Fund, where Dybul must navigate funding shortfalls and structural reform.
The Global Health Campus in Geneva, headquarters of the Global Fund, where Dybul must navigate funding shortfalls and structural reform.

Dybul, who also previously served as the US Global AIDS Coordinator from 2006 to 2009, takes charge as recipient countries press for greater health sovereignty. Under Grant Cycle 8, 63 disease components across 35 countries and three multi-country contexts are scheduled to receive their final grant allocation as they transition toward domestic financing, according to the Global Fund in response to a query by Health Policy Watch.

Addressing the urgent execution timetable for these shifts, Dybul warned in a recent Devex podcast interview that implementing countries must rapidly establish national governance, data systems, and transition units before donor budget reductions take full effect.

“There is a very narrow window of opportunity – 12 to 18 months – to get it right this time,” Dybul said regarding health transitions. “If we focus on supporting countries for what they want and need now, where we are in five years could be so dynamic and exciting.”

Demonstrating measurable country-led progress within this timeframe, he noted, will be essential to maintaining donor confidence across international capitals.

“Mark understands that the future of global health depends on greater country ownership, self-reliance and sustainable health systems,” said Bience Gawanas, the board’s vice-chair. “Under his leadership, the Global Fund will support countries to accelerate this transition while ensuring that the most vulnerable communities are not left behind.”

Broader leadership turnover

The transition coincides with a broader leadership turnover across the organisation’s top governance bodies. Morauta and Gawanas will hand over board governance stewardship to former Norwegian Prime Minister Erna Solberg and Argentinian Javier Hourcade Bellocq, who has served in “multiple capacities” at the Global Fund, including on the board representing the Communities Delegation.

“As incoming board leadership, Javier and I look forward to working with Mark to build on two decades of success while embracing innovation and new partnerships,” said Solberg.

Outgoing executive director Peter Sands, who has led the partnership since 2018, mobilised record investments and expanded access to breakthrough health innovations during his tenure.

Health Policy Watch reached out to Dybul for comment regarding his incoming strategic priorities, but he did not respond to requests before publication.

Experts welcome appointment, urge leadership adaptation

The Global Fund has saved 72 million lives and reduced combined mortality across AIDS, tuberculosis, and malaria by 63% since 2002, and global health leaders and observers welcomed Dybul’s appointment, citing his proven credentials to guide the Global Fund through turbulent times.

IGHD president and former Guinea-Bissau Health Minister Magda Robalo.
IGHD president and former Guinea-Bissau Health Minister Magda Robalo.

“This strategic choice reflects a preference for proven institutional experience and strong donor relationships over the potential disruption and steep learning curve associated with new leadership at a time of unprecedented uncertainty,” said Magda Robalo, president of the Institute for Global Health and Development and former Minister of Health of Guinea-Bissau, responding to a query by Health Policy Watch.

However, she stresses that the global health landscape has fundamentally transformed since Dybul’s previous term as executive director in 2017: rising nationalism, aid scepticism, and country demands for health sovereignty mark significant challenges.

Acknowledging that donor-driven models of the past must be reframed, Robalo highlights Dybul’s recent engagement with the Accra Reset reform agenda as a key asset to navigate this altered context.

“The key question is not whether he can lead the Global Fund he once managed, but whether he can adapt his leadership to a profoundly altered context and help redefine the institution’s role and future in a changing world,” said Robalo.

Mandate dilemmas and community safeguards

Policy experts like former Global Fund Board member Jirair Ratevosian emphasise that the incoming chief faces defining strategic choices regarding the organisation’s core identity and long-term scope.

Policy strategist and former Board member Jirair Ratevosian.
Policy strategist and former board member Jirair Ratevosian.

Key decisions loom over whether the Global Fund should strictly maintain its specialised focus on the three epidemics or broaden investments toward health security, climate resilience, and primary healthcare. Simultaneously, the secretariat faces pressure to absorb higher financial risk to accelerate market access for breakthrough tools, including long-acting injectable HIV prevention and AI-driven diagnostics.

As national governments assume greater operational control, key population advocates and civil society leaders insist that community leadership must remain central to the response.

Welcoming Dybul’s appointment, Global Black Gay Men Connect (GBGMC) urged the incoming leadership to ensure that transition frameworks do not force marginalised groups to absorb funding cuts or wait for state action.

“The next phase needs a sustainability plan that does not leave communities waiting for governments and donors to act, or absorbing funding cuts on their own,” said Micheal Ighodaro, executive director of GBGMC, in a statement. “It must build lasting community power, financing, institutions and leadership, alongside the public and donor resources that remain essential.”

Transatlantic rifts and new tech philanthropy

The German Bundestag in Berlin. European donors face calls to step up financial commitments rather than complain about diminishing influence in Geneva.
The German Bundestag in Berlin. European donors face calls to step up financial commitments rather than complain about diminishing influence in Geneva.

To offset sovereign aid declines, Dybul will also have to navigate non-traditional financing, including controversial discussions around multi-billion-dollar AI and tech philanthropy.

Crucially, rebalancing governance to grant recipient nations greater strategic weight will require delicate diplomacy – particularly in securing sustained backing from the United States as Washington increasingly shifts toward bilateral health compacts under its America First Global Health strategy.

He will also have to engage with European donor countries despite recent nomination frictions. Speaking to Health Policy Watch on the condition of anonymity, senior global health officials said that if European nations want a larger decision-making role, they must “step up.”

Another senior European health policy source added: “Europe is paralysed by its own weakness,” reflecting growing frustration over the continent’s struggling influence and lack of strategic vision.

Ultimately, Dybul’s return signals a defining moment for the future of multilateral health architecture. As the Global Fund confronts fiscal contraction and shifting global power dynamics, the new chief must reconcile donor expectations with country sovereignty – ensuring that the drive for structural reform does not compromise the frontline fight against AIDS, tuberculosis, and malaria.

See related story:

Who Should Lead the Global Fund? Let the Candidates Make Their Case

Note: Figures regarding the Eighth Replenishment total and Grant Cycle 8 transition components were updated.

Image Credits: Georgetown University, Global Fund/Vincent Becker, Felix Sassmannshausen/HPW, Milken Institue, Claudia Solano via Pexels.

UNAIDS executive director Winnie Byanyima (centre) and Programme Co-ordinating Board (PCB) chair Ambassador Erica Schouten (left) at the special meeting to decide on the way forward for UNAIDS.

The UNAIDS Programme Coordinating Board (PCB) has rejected the proposal by the United Nations Secretary-General that it is “sunsetted” by the end of this year, opting instead to transform into a smaller “hub”.

This emerged after the PCB’s special meeting on Monday, which considered a report by a working group on the body’s future. The working group recommended that the body is transformed into a much smaller, more focused body rather than sunsetted in the next few months.

“You have rejected the sunsetting of UNAIDS and chosen instead to transform and strengthen this unique joint programme,” said UNAIDS Executive Director Winnie Byanyima in a statement issued on Tuesday.

“I thank programme countries, donors, civil society and activists who stood firm and fought for the future of UNAIDS. Saving the joint programme is only the beginning. Now we must transform it and get that transformation right.” 

The board has charged the executive director with establishing a “transition task team, comprising secretariat and cosponsor representatives and two community representatives nominated by the PCB NGO delegation”, according to a UNAIDS media release. 

“The team will work closely with implementing countries, consult relevant joint programme stakeholders and be accountable to the board for delivering a fully costed implementation plan.”

However, Byanyima’s term ends at the end of December, so the UN Secretary-General will need to appoint an interim replacement to manage the transition process. 

PCB chair Ambassador Erica Schouten, the Netherlands representative to the UN in Geneva, has been tasked with reporting the UNAIDS decision to the United Nations Economic and Social Council (ECOSOC).

The UN is facing a dire funding shortage, and its proposal to “sunset” UNAIDS was part of its cost-cutting plan. 

Tighter secretariat

The working group proposes a strong and focused secretariat (or “hub”) to lead the UN’s HIV work in four core functions: leadership and advocacy; convening and coordination; accountability, data and targets; and community support.

The secretariat will provide cross-cutting leadership for the Global AIDS Strategy, which aims to end AIDS by 2030. It will also coordinate UN joint action on HIV, and data and accountability for meeting global AIDS targets. 

Meanwhile, UNAIDS presence in affected countries is expected to evolve over time, with the aim of integrating country-level functions into national institutions.

However, the Joint Programme will “need to have a clear presence in all regions to carry out functions that are performed more efficiently at this level, such as monitoring and evaluation support, facilitation of south-south learning, technical or crisis capacity, and engagement with political and technical bodies, the working group notes”.

UNAIDS has already slashed its global staff from 608 to 294, with only 19 located at its large headquarters in Geneva. The remaining UNAIDS secretariat staff are currently employed across these four core functions, and around two-thirds of staff are located in sub-Saharan Africa. 

Staffing accounts for 55% of the secretariat’s 2026 budget of $ 85.1 million, with 39% devoted to activities.

Bigger role for co-sponsors

A central pillar of the transformation of UNAIDS rests on its co-sponsors – 10 UN agencies and the World Bank – taking “stronger leadership in technical areas”. 

The working group report notes that the co-sponsoring agencies have “expertise in diverse sectors and a presence in more than 130 countries” and should be “the primary implementer of the UNAIDS Joint Programme’s technical work”. 

It recommends “ceding all technical and programme implementation functions to the co-sponsors”, proposing that they be mandated to “take leadership of the individual result areas of the Global AIDS Strategy”.

The working group report also notes that four co-sponsors employ dedicated HIV staff, including the World Health Organization (117 HIV-focused staff), UN Population Fund (75), UN Development Programme (74), and UN Children’s Fund (more than 60). 

A pool of funding will be maintained to support co-sponsor-led and co-sponsor-facilitated work at country level. 

The working group also notes that functions that require proximity to communities living with, and affected by, HIV should be led by community and civil society actors.

Areas of uncertainty 

However, there are still issues to be worked out. The working group noted that its members had “differences of opinion” over “the optimal length of the transition process; whether the UNAIDS Joint Programme should retain a standalone country presence or be fully integrated into existing UN or national-level institutions; and whether budgeting should be function-led or made to fit within an agreed funding envelope.”

It also notes that stakeholders “expressed divergent opinions as to whether a new executive director should be named or an interim director should manage the transition, with a permanent executive director named thereafter.”

Rubbish-laden trucks queue along a muddy access road at Pugu Kinyamwezi dumpsite in Dar es Salaam, where the disposal of the city’s waste poses environmental and public health challenges.

DAR ES SALAAM, Tanzania — The smell of burning garbage wafted into Ester Kayombo’s bedroom, jolting her awake with the fear that her house was on fire.

Nearby, heaps of rubbish were burning at the Pugu Kinyamwezi dumpsite, sending plumes of smoke billowing across the neighbourhood.

Kayombo, a mother of three, feared for her three-year-old daughter, Eliza, who has asthma. She wedged a wet cloth under the door and opened a rear window, hoping to clear the smoke. She clutched Eliza’s inhaler and listened anxiously as her daughter breathed.

“The smoke was so thick that my daughter struggled to breathe,” Kayombo said.

Kayombo, a street cook selling Ugali, rice, beans, meat and vegetables near the Pugu cattle market, is not considering leaving the house despite frequent fires, smoke and the strong smell from the dumpsite. 

Like millions of poor city dwellers across Sub-Saharan Africa, she faces a difficult choice between environmental health hazards and economic survival.

“My landlord is very kind. If I’m late paying the rent, he understands,” she told Health Policy Watch. “I rely on this market for my livelihood. I have nowhere else to go.”

Governance failure

The Pugu Kinyamwezi fire burned for a week, engulfing the impoverished neighbourhood in smoke. Firefighters struggled for days to control the blaze. A senior firefighter, speaking on condition of anonymity, revealed the critical operational deficits facing emergency services. 

“We don’t have enough water tankers, fire retardant foam, and protective gear for longer chemical fire exposure,” he told Health Policy Watch.

Over six million people live in the city, one of the fastest growing on the continent. Many people live in informal settlements, and there is a serious waste management crisis. 

The city produces roughly 5,600 tonnes of waste daily, but less than 40% is formally collected, according to Dar es Salaam City Council Statistics. Across crammed neighbourhoods, trash – including food and plastic bottles – often litters the streets, clogging drains and increasing flood risk in the rainy season.

The Pugu Kinyamwezi dumpsite sprawls across 65 hectares and receives about 2,500 tonnes of mixed rubbish a day, which is beyond its capacity.

“We receive more rubbish than we can handle. Food waste and organic matter release methane, which often causes fires in the dry season,” said Philip Benno, head of the City Council’s Waste Management Directorate. 

Benno said the government is seeking investors to modernise the dump, aiming to turn it into a sanitary landfill that is capable of generating energy from waste. 

However, policy analysts say progress has been stalled by regulatory hurdles and delayed public-private partnership (PPP) frameworks.

Philip Benno, head of the Dar es Salaam City Council’s Waste Management Directorate, at the Pugu Kinyamwezi dumpsite in Dar es Salaam. Poor waste management and smoke from dumpsite fires are affecting the health of surrounding communities.

Air quality data

Burning mixed municipal waste releases fine particles, heavy metals and toxic gases into the air, environmental health experts say.

A study by researchers from the Dar es Salaam Institute of Technology and Stockholm Environment Institute analysed measurements from 14 monitoring stations between May 2021 and February 2022. 

Daily average concentrations reached up to 130.45 micrograms per cubic metre (µg/m³) for fine particles (PM2.5), and 184.15 µg/m³ for the coarser PM10.  

The monitoring station at Pugu ‘Dampo’ recorded the highest pollution levels. The peak PM2.5 reading was almost nine times WHO’s 2021 guideline of 15 µg/m³ over 24 

“While our study did not collect direct patient data, the measurements clearly showed concentrations several times above WHO safe limits,” said Jacqueline Senyagwa, an SEI researcher and co-author of the study.

Health impacts 

Globally, air pollution causes 7.9 million premature deaths annually, with over 90% occurring in low- and middle-income countries, according to the World Health Organisation. 

Aside from the human toll, the World Bank estimates that air pollution costs the global economy nearly 5% of global GDP, and targeted policies could lower the number of people exposed to dangerous levels by 2040, with economic benefits of up to $2.4 trillion.

At the local level, health facilities bear the direct brunt of pollution spikes.

“During landfill fires, we see a rise in paediatric outpatient visits for acute asthma attacks, bronchitis, and upper respiratory tract infections,” said Dr Daniela Tarimo, a physician at Kivule District Hospital. 

“Children are disproportionately vulnerable because their lungs are still developing and they breathe more air per kilogram of body weight than adults.”

Local clinics report that stocks of basic bronchodilators and paediatric nebuliser kits often run dangerously low during extended fire episodes, leaving low-income families to purchase medications out-of-pocket at commercial pharmacies.

More than a third of respondents reported burning their rubbish in a survey of 217 households in Dar es Salaam’s Tandale, Manzese and Tandika wards, exposing a gap in waste disposal services with implications for public health. 

The study, by Felician Andrew Kitole and colleagues, found that 61% of households had no access to waste collection services. As a result, 35.9% burnt their waste, and 41.9% used open dumpsites. 

Respiratory infections were reported in 14% of households, which researchers linked to waste burning and poor air quality. Other illnesses included diarrhoeal diseases (39% of households), malaria (28%), typhoid (9%), skin infections (5%) and cholera (3%). Researcher linked these conditions with some of the consequences of poor waste management, including contaminated food and water, stagnant water that provides mosquito breeding sites, and contact with polluted materials.

The authors recommended more frequent rubbish collection, community-led waste programmes and subsidised bins and waste bags. However, the study captured conditions at a single point in time, and did not establish how many people across Dar es Salaam were affected by waste-burning pollution or prove that burning caused the reported infections.

Struggling with rubbish 

Municipal workers negotiate waterlogged ground between heaps of mixed rubbish at Pugu Kinyamwezi dumpsite in Dar es Salaam. The accumulated waste highlights the scale of the city’s disposal challenge.

Environmental experts say dumpsite fires are caused by deliberate or accidental burning, flammable materials and heat generated by organic waste.

Zainabu Katima, who lectures in environmental sanitation at the University of Dar es Salaam’s College of Engineering and Technology, said household rubbish, discarded plastics and rubber can cause hard-to-control fires.

“When different types of waste are dumped together without being sorted, a small fire can spread quickly,” she told Health Policy Watch.

The WHO links air pollution to heart disease, stroke, chronic obstructive pulmonary disease and lung cancer. Fine particles can travel deep into the lungs and pass into the bloodstream.

“When plastics and other synthetic materials burn with household rubbish, they can release fine particles and harmful gases into the air,” said Regina Kilima, an environmental health researcher at the National Environmental Management Council

For children with asthma, such as Eliza, smoke exposure can worsen symptoms and trigger severe breathing difficulties.

Weak monitoring

Tanzania has environmental laws and air quality regulations, but limited monitoring and overlapping institutional responsibilities hamper pollution control, experts say.

Despite weak enforcement, poorly coordinated oversight, and a lack of pollution monitoring equipment, community groups in Dar es Salaam are devising their own mechanisms to tackle air pollution.

In the densely populated Kimara neighbourhood, the Tanzanian environmental organisation, Nipe Fagio (Swahili for “Give Me a Broom”), has organised women to collect household waste and separate organic matter, recyclables and hazardous materials. The work provides income and reduces the amount of waste sent to dumpsites.

It supports Zero Waste cooperatives, made up of waste pickers, women and youth, that generate income from collecting waste, recyclables, maggot farming, composting and urban farming.

“Community initiatives prove that sorting waste at home is possible, but we need municipal-scale investments to bridge the gap,” said Wilyhard Shishikaye, a coordinator with Nipe Fagio.

Nipe Fagio trains waste pickers to recycle waste through Zero Waste cooperatives.

Making clean air a public health priority

Health policy experts are calling on Tanzania to expand air pollution monitoring in urban areas and make the readings publicly available. They also recommend upgrading open dumpsites such as Pugu Kinyamwezi into sanitary landfills with proper waste handling and methane collection systems.

This would require environmental regulators, local councils and health authorities to work more closely together. Experts say the National Environment Management Council and councils need the staff, equipment and funding to enforce restrictions on waste burning. Health centres also need clear procedures for treating patients with breathing difficulties during severe pollution episodes.

Residents living near garbage dumps need to receive timely warnings about fires and clear advice about how to reduce their exposure to smoke and access to medical care.

Their ability to protect themselves often depends on what they can afford. Some families may be move away, but many cannot afford to. 

For Ester Kayombo and her daughter Eliza, structural reforms cannot come soon enough. As long as urban waste management remains underfunded, the burden of toxic smoke will continue to fall heaviest on those unable to escape it.

Image Credits: Zuberi Mussa, Nipe Fagio.

C02 levels have reached record highs in the atmosphere, according to the latest WMO bulletin.

The levels of major greenhouse gases reached record highs in 2025, locking in more long-term temperature rise for the planet, according to a new bulletin from the World Meteorological Organization (WMO).

Among the greenhouse gases, the levels of carbon dioxide (CO2) and methane (CH4) continue to dominate.

In its latest Greenhouse Gas Bulletin, the WMO reported that the globally averaged surface concentration of CO2 in 2025 was 426.8 parts per million, or 153% of the 1750 pre-industrial baseline.

“Another year, another new record. Greenhouse gases are trapping an unprecedented amount of heat in the atmosphere, providing energy for more extreme weather and associated risks to our economies and societies,” said WMO Deputy Secretary-General Ko Barrett.

“The past 11 years have been the warmest on record, and this trend is set to continue. CO2 has a very long lifetime and so will affect the global climate not just for years but for decades and even centuries.”

Concentrations of nitrous oxide, the third most important long-lived greenhouse gas related to human activities, also rose to a new record.

In the summer of 2025, over 50,000 people died from heat in Europe, the region heating fastest in the world, according to a recent study published in Nature.

Researchers used statistics from 854 European cities from heat waves in June, July and August, and found that 50,391 people died from warmer temperatures, and that “68% of the estimated heat-related deaths in 2025 were attributable to human activity”.

Global leaders are set to meet in Antalya, Türkiye, in November to once again seek to turn climate commitments into concrete actions at the annual UN climate conference COP, now in its 31st year.

CO2 growth rates tripled

Globally averaged CO2 concentration (left) and its growth rate (right) from 1984 to 2025. Observations from 179 stations were used for this analysis.

Growth rates of CO2 have tripled since the 1960s, accelerating from an annual average increase of 0.8 ppm per year to 2.4 ppm per year in the decade from 2011 to 2020. From 2024 to 2025, the global average concentration of CO2 rose by 2.8 ppm – above the decadal average but slightly less than the exceptional surge of 2023-2024.

“The more modest growth rate from 2024 to 2025 reflects recovery of the land carbon sinks and reduced fire carbon emissions in 2025 after the strong 2023-2024 El Nino, which reduced the efficiency of the biosphere through more drought, drier vegetation and more wildfires,” said WMO senior scientific officer Oksana Tarasova.

Nearly half of the CO2 released in the atmosphere is absorbed by the water bodies and land sinks like forests and wetlands.

“However, a 2.8 ppm annual increase is still a substantial addition of carbon to the atmosphere from fossil fuel burning. We can expect to see a further increase in concentrations in 2026 because of fossil fuel burning and the development of a powerful El Niño which will impact land carbon sinks as it did in 2023-2024. The risks of reduced CO2 uptake by the ocean are also increasing in our changing climate,” Tarasova said.

Other greenhouse gases are also rising

Contribution of the most important long-lived greenhouse gases to the increase in global radiative forcing from the pre-industrial era to 2025.

Currently, methane accounts for about 16% of the warming effect on our climate by long-lived greenhouse gases, but it has a much shorter lifetime than CO2.

Around 35% of methane is emitted into the atmosphere by natural sources (for example, wetlands) which are sensitive to climate as well, and about 65% comes from anthropogenic sources such as cattle, rice farming, fossil fuel exploitation, landfills and biomass burning.

Global efforts are on to reduce methane emissions, especially in the agriculture sector.

The bulletin also warns countries to pay careful attention to two potent but less abundant trace gases closely related to electricity production and distribution: molecular hydrogen (H2) and sulphur hexafluoride (SF6).

The increase in SF6 in 2025 was a record high. It has been rising steadily over the past three decades in proportion to increased global electrification, since SF6 is used primarily as a spark suppressant in electricity distribution. It has an atmospheric lifetime of over 1,000 years, and its 100-year global warming potential is approximately 24,300 times that of CO2.

Hydrogen concentration has also increased by 5.3% between 2010 and 2024. Hydrogen is being used as an energy storage medium for hard-to-decarbonize sectors such as steelmaking, shipping, and long-duration energy storage, as well as for renewable sources and as an energy source for transport.

Its leakage into the atmosphere from production facilities, pipelines, storage tanks, and fuel cells poses a growing concern. Hydrogen is not a greenhouse gas, but it influences atmospheric chemistry and so has a strong indirect effect on warming.

Image Credits: WMO, WMO.

Who will steer the World Health Organization through its next chapter? Explore Health Policy Watch’s daily series examining the platforms, records, and institutional hurdles facing each contender for WHO Director-General, continuing today with Song Li. Access all candidate profiles on our dedicated election site.

Framed by Beijing as advancing a “community of health for all”, Song’s prospective platform will likely centre on primary care and South-South cooperation.
Framed by Beijing as advancing a “community of health for all”, Song’s prospective platform will likely centre on primary care and South-South cooperation.

The formal confirmation of Dr Song Li’s candidacy by the People’s Republic of China on 8 October expands the official election field for WHO Director-General to seven candidates, following an initially tight-lipped rollout by Beijing. Her bid introduces into the race a senior public health administrator and physician-scientist whose two-decade career at China’s National Health Commission (NHC) has centred on scaling primary healthcare, maternal and child health, and integrated disease prevention.

Her nomination fundamentally reshuffles the candidate field amid escalating US-China superpower competition, a geopolitical backdrop underscored by her political role on the Secretariat of the Communist Party-led All-China Women’s Federation (ACWF).

While Song has not released a standalone campaign manifesto, China’s Ministry of Foreign Affairs framed her bid around reinforcing multilateralism upon confirming her candidacy. Outlining her administrative record in a subsequent written response to Health Policy Watch, the country’s Permanent Mission in Geneva stated: “She has a strong track record of translating policies into concrete actions, with demonstrated capabilities in strategic leadership, policy development, programme implementation, organizational management and cross-sectoral coordination.”

Prospective programmatic framework

Speaking at the 2023 WPRO hearing, Song Li outlined her vision prioritising equitable health emergency response, and primary care delivery.
Speaking at the 2023 WPRO hearing, Song Li outlined her vision prioritising equitable health emergency response, and primary care delivery.

In the absence of a formal campaign manifesto, Song’s prospective platform can be anticipated across four core public health pillars – drawn from the Mission’s statement, her administrative background at the NHC, and disclosures from her unsuccessful 2023 campaign for Western Pacific regional director:

  1. Primary healthcare and maternal-child health equity: Grounded in her decades long record contributing to national maternal and child health programmes at the NHC, Song’s prospective platform is expected to prioritise primary healthcare (PHC) as the core engine for Universal Health Coverage (UHC). Her field leadership – which included scaling hospital delivery subsidies to 100 million rural women and advancing mother-to-child disease elimination – reflects a long-standing domestic emphasis on strengthening frontline community health services to reduce geographical and economic barriers for vulnerable populations.
  2. Healthy ageing and NCD prevention: Addressing rapid demographic change and non-communicable diseases in her 2023 WPRO bid, Song rejected viewing ageing as an economic liability, advocating instead for “elderly-friendly societies, communities, and hospitals.” Her technical background highlights life-course prevention – integrating NCD management directly into primary care systems to “turn silver into gold” through healthy longevity.
  3. Pathogen Access and Benefit-Sharing (PABS): Drawing on her two decades leading national health administration and epidemic response (SARS, COVID-19 protocols), Song explicitly aligned herself with calls to strengthen global health security governance through the Pandemic Agreement. Her record corresponds with Global South demands in the PABS negotiations for mandatory benefit-sharing and equitable access to emergency countermeasures.
  4. South-South cooperation: Having contributed to the China-Africa Health Cooperation Framework through its Women and Children’s Health Action Plan, and worked on Belt and Road health cooperation, Song brings a record that directly reflects Beijing’s health diplomacy and expanding soft-power footprint. This points to a prospective platform centred on country-led health capacity. During her 2023 candidate remarks, she emphasised moving away from donor dependency toward sustainable national self-reliance, supporting regional laboratory networks, local vaccine and diagnostic manufacturing, and costed national health plans.

This profile extends beyond her individual technical record. Her candidacy is fundamentally anchored in China’s active steering of broader institutional restructuring. As co-chair of WHO’s Joint Task Force on Global Health Architecture Reform alongside Germany, Beijing has positioned itself as a direct architect of future governance, institutional realignment, and multilateral funding mechanisms.

From clinical care to national public health

Shandong University’s Central Campus in Jinan. Song trained in obstetrics and gynaecology at the institution’s medical school before entering national public health.
Shandong University’s Central Campus in Jinan. Song trained in obstetrics and gynaecology at the institution’s medical school before entering national public health.

Born in 1974, Song began her career in clinical medicine, earning a Master’s degree in Obstetrics and Gynaecology from Shandong Medical University (1997-2000) and practising in gynaecologic oncology. Seeking to address systemic disease drivers at population scale, she transitioned to public health policy, joining the Ministry of Health (now the National Health Commission) in June 2002 as a programme officer in the women’s health division.

Her early administrative career was quickly defined by crisis management and academic accomplishments. During the 2003 SARS outbreak, she served in the national Emergency Operations Center, and following the 2008 Wenchuan earthquake in Sichuan Province, she led an on-site medical emergency team to oversee post-disaster maternal healthcare reconstruction. While advancing through the ministry, she deepened her technical credentials, completing a PhD at Peking University (2006-2010) alongside a visiting scholarship in global health at Harvard University in 2010.

During the COVID-19 pandemic, Song authored national protection protocols for pregnant women, published national guidance Q&As for maternal care, and facilitated international experience-sharing with global health partners. Her two-decade ascent through the ministry culminated in March 2021 with her appointment as Director-General of the Department of Women and Child Health, where she directed national strategic policies, legislation, and public budgets.

Building maternal care and national programmes

Beyond acute emergency response, Song’s domestic legacy centres on converting targeted interventions into permanent primary healthcare infrastructure. Her signature operational initiative directed hospital delivery subsidies to 100 million rural pregnant women.

According to official Chinese statistics, this initiative raised rural hospital birth rates from under 50% to over 99%, driving national maternal mortality down to 15.7 per 100,000 live births in 2022 – well ahead of the global UN Sustainable Development Goal 3.1 target of fewer than 70, though significant disparities persist between affluent eastern provinces and remote western regions.

Her technical work also centred on disease elimination and inter-ministerial financing. In 2002, Song contributed to China’s first integrated pilot programme in Henan Province to prevent mother-to-child transmission of HIV, syphilis, and hepatitis B, expanding it to nearly 3000 counties nationwide.

To reduce care delays, she advocated the adoption of rapid diagnostic testing that cut result waiting times from 14 days to 30 minutes – a key operational shift within the comprehensive national prevention package, which official records credit with driving HIV mother-to-child transmission down from 34.8% to 3%.

Song sustained these programmes by embedding maternal health priorities directly into China’s Five-Year Plans, leveraging the State Council’s Working Committee for Women and Children to secure multi-ministerial funding from the Ministry of Finance and the National Development and Reform Commission.

Financial and political weight of an emerging superpower

China emerges as the largest state contributor in mandatory assessed dues to WHO, trailing only three non-state and multilateral donors overall.
China emerges as the largest state contributor in mandatory assessed dues to WHO, trailing only three non-state and multilateral donors overall.

Song’s nomination coincides with a major shift in global health governance following the declared withdrawal of the United States from WHO. Beijing has stepped into this funding landscape with significant financial weight, backed by $320.1 million in projected biennial WHO contributions for 2026-2027. This includes $275.7 million in mandatory assessed dues, making China the largest active state contributor in assessed funding. However, China is not the largest donor overall; it ranks fourth behind non-state and multilateral entities like the Gates Foundation, the European Commission, and the World Bank.

Politically, China secured a seat on the 34-member WHO Executive Board starting in May 2026, positioning Beijing as an insider during the critical screening process in January 2027. Under WHO election procedures, candidates must first clear a 10% threshold of members present and voting to reach a shortlist of up to five. To then be nominated among the up to three candidates submitted to the World Health Assembly, a contender must secure a simple majority of members present and voting on the Executive Board.

This financial and political weight mirrors China’s transition over the past two decades from an international health aid recipient into a major multilateral donor. Song’s personal career trajectory – from directing World Bank-supported rural health initiatives to Belt and Road health cooperation – embodies Beijing’s strategic transformation from domestic capacity-building to projecting global health influence, drawing scrutiny from traditional Western donors.

Geopolitical scrutiny and institutional obstacles

The WHO team arrives in Wuhan in January 2021 - a mission whose unresolved questions form the backdrop of diplomatic scrutiny facing Song’s candidacy.
The WHO team arrives in Wuhan in January 2021 – a mission whose unresolved questions form the backdrop of diplomatic scrutiny facing Song’s candidacy.

Despite her technical credentials, Song’s candidacy encounters formidable diplomatic headwinds rooted in broader Western concerns over China’s expanding political footprint. Global health analysts observe that a Chinese candidate heightens geopolitical friction, drawing strong bipartisan opposition in Washington and rendering potential US re-engagement with WHO far more politically complex. This scrutiny is compounded by residual diplomatic friction over early COVID-19 transparency and persistent US allegations of institutional bias.

Beyond political criticism, WHO’s independent Scientific Advisory Group for the Origins of Novel Pathogens (SAGO) assessed that origin investigations remain inconclusive. SAGO cited missing baseline data, including raw epidemiological files, Wuhan laboratory audit records and staff health logs, and testing data for upstream animal supply farms. While available peer-reviewed evidence favours a natural zoonotic spillover, SAGO stressed that neither the exact transmission pathway nor a research-related incident can be confirmed or eliminated without these withheld records.

In its written response to Health Policy Watch, China’s Permanent Mission in Geneva did not address specific enquiries regarding Song’s strategy for maintaining scientific independence, supporting compliance with the updated International Health Regulations (IHR), or resolving WHO’s budget constraints. Instead, the Mission confined its response to an overview of her administrative track record, noting that further materials would be shared “in due course.”

Furthermore, member states face institutional hesitation regarding executive concentration, noting that China already held the WHO leadership for two consecutive terms under dual Chinese and Canadian citizen Dr Margaret Chan (2007-2017). While Chinese national Qu Dongyu’s second term leading the Food and Agriculture Organization (FAO) concludes in July 2027, his concurrent tenure throughout the 2026-2027 campaign window might reinforce resistance in several capitals against placing a second major UN specialised agency under Chinese executive leadership.

Those reservations have been compounded by controversy surrounding Qu’s leadership style. At a recent FAO assembly in Rome, Qu drew international criticism after warning senior officials that “we’re not allowing you to play the game here of human rights” and insisting that human rights governance belongs strictly in Geneva. The episode has sharpened broader diplomatic anxieties over how Chinese executive leadership manages cross-cutting UN mandates, particularly given Beijing’s tendency to prioritise state-led development over universal human rights frameworks.

A test of technical authority in disruptive times

The 2023 inauguration of Africa CDC’s headquarters in Addis Ababa, financed by Beijing, highlights China’s expanding health diplomacy footprint across the Global South.
The 2023 inauguration of Africa CDC’s headquarters in Addis Ababa, constructed by Beijing, highlights China’s expanding health diplomacy footprint across the Global South.

Song’s candidacy brings a distinctive profile to the race: a physician-scientist and technical administrator whose career centres on primary care equity and South-South health cooperation. For member states seeking a technical reformer aligned with Global South health sovereignty, her domestic record at the National Health Commission offers a concrete template of country-led implementation.

However, her path to Geneva faces steep diplomatic and structural hurdles. To build a winning coalition beyond Beijing’s core voting bloc, Song must convince sceptical capitals of her institutional independence. She must also navigate lingering geopolitical friction over early pandemic transparency, bipartisan opposition in Washington, and member state hesitation regarding Chinese leadership concentration across UN agencies.

Ultimately, her bid forces member states to weigh two competing visions for WHO’s post-US era. One path opts for a senior technical administrator focused on frontline primary care and South-South self-reliance. The other prioritises alternative candidate profiles designed to restore traditional Western donor confidence, and safeguard normative neutrality amid intensifying superpower rivalries.

Note: Health Policy Watch reached out to Song for comments but has not received a response ahead of publication. Profiles will be updated as the campaign progresses, stay tuned on the microsite.

Image Credits: WHO, Shandong University, WHO/HPW, CGTN, African Union.

A patient has his blood pressure tested. People living with diabetes face far higher risk of blood pressure and heart disease.

Over 100 million people in India are estimated to be living with diabetes, and many with the most common form, type 2 diabetes, delay insulin therapy by seven to nine years, according to studies. Dr Viswanathan Mohan, one of India’s leading endocrinologists, explains some of the facts and myths about the condition. 

Health Policy Watch: Why do people in India delay insulin treatment for years, even when it is medically necessary?

Leading Indian endocrinologist Dr V Mohan

Dr V Mohan: It is not just in India. People around the world are reluctant to take insulin because they believe that once they start, they will have to take it for the rest of their lives. In India, people also tend to associate starting insulin with the end of their lives.

They may have seen a patient admitted to an intensive care unit in a critical condition, given insulin and subsequently die. In some cases, the patient may have died from other causes, such as heart failure or multiple organ failure. But people interpret such instances as evidence that starting insulin means the end is near.

In reality, it is quite the opposite. When other medications fail to control blood sugar levels adequately, insulin may be the most appropriate treatment.

Some people also mistakenly believe that insulin is an addictive substance, like narcotic drugs. These are all myths.

HPW: Why do some people believe insulin is addictive, and can patients stop taking it once they start?

Dr V Mohan: This is a myth. Insulin is a life-saving medication, and it is not addictive. A person can stop taking insulin if their clinical condition allows it and their doctor recommends doing so

There is also a view, which I share, that when blood sugar levels are very high in the early stages of diabetes, particularly when someone has been diagnosed late or has gone undiagnosed for a long time, a short course of insulin can have lasting benefits. Even if a patient takes insulin for just one month, with one injection a day for 30 days, the benefits may persist for years in some cases.

HPW: Do all patients with diabetes eventually need insulin?

Dr V Mohan:  It is important to distinguish between the different types of diabetes. In type 1 diabetes, the body produces little or no insulin, making insulin therapy essential for survival. Although type 1 diabetes accounts for a smaller proportion of cases and is often diagnosed in children and young people, adults can develop it too.

This discussion, however, focuses on type 2 diabetes, which accounts for the vast majority of diabetes cases worldwide. Unlike type 1 diabetes, insulin is not necessary for every person with type 2 diabetes. Depending on their individual circumstances, some patients can manage their blood sugar levels through dietary changes, exercise and oral medications.

However, when blood sugar levels remain very high or other treatments fail to provide adequate control, insulin may become necessary.

Doctors sometimes continue adding oral medications even when the additional benefit from each drug becomes progressively smaller. The first medication might reduce a patient’s HbA1c level, a measure of average blood sugar, by two percentage points. A second drug might bring a further reduction of one percentage point, while a third might lower it by only 0.3 or 0.4 percentage points. The benefit may diminish further as additional drugs are introduced.

At that stage, doctors may recommend insulin to bring blood sugar levels under control. But patients can remain reluctant, viewing insulin as a last resort rather than a necessary step in managing their condition.

‘This is the time when we recommend insulin, but people resist, saying that insulin is the last thing they would want to take,’ Mohan says.

HPW: Have newer treatments changed this situation? And has the World Health Organization’s Global Diabetes Compact improved access to care?

Dr V Mohan: We now have newer drugs, including GLP-1 medicines, which have been available in India for the past year or two. When two or three oral therapies fail, doctors may prefer these drugs before insulin. However, they have their own constraints, particularly their high cost.

As far as the WHO Global Diabetes Compact is concerned, it has helped raise awareness about the rights of people with diabetes. One of its aims was that no adult or child with type 1 diabetes should die because of a lack of insulin. Insulin was recognised as a fundamental necessity, and global benchmarks were established.

However, whether these commitments have translated into measurable improvements in the quality of care is not something I can point to a formal study on. Awareness has certainly increased.

insulin pens in egypt
Insulin pens have made it easier for people with diabetes to administer the drug themselves.

HPW: Does insulin have any side effects?

Dr V Mohan: Insulin is a miracle drug because it can reduce blood sugar levels in people with diabetes. But it has some side effects. One is weight gain, because insulin is a hormone. Another is hypoglycaemia, or low blood sugar, which patients need to be aware of and know how to manage.

HPW: With GLP-1 drugs now available, can patients avoid insulin altogether?

Dr V Mohan: Certainly not. In complicated situations, insulin remains essential. For example, it is used in the management of blood sugar during surgery and in certain acute medical situations, including heart attacks and strokes. During the COVID-19 pandemic, insulin was also used to manage blood sugar levels in patients who needed it. Newer medicines do not mean insulin is no longer necessary. The appropriate treatment depends on the patient’s condition.

HPW: Clinical inertia has also been identified as a reason for the seven-to-nine-year delay in insulin treatment. What role do doctors play?

Dr V Mohan: It is not only patients who are responsible for these delays. Doctors can also contribute to them. Prescribing a tablet is relatively simple: a doctor can tell a patient to take it in the morning or afternoon, before or after a meal. Insulin requires much more instruction and time.

Doctors must teach patients how to inject insulin, where to inject it, how deep the injection should go and how to rotate injection sites. They must also explain how to recognise and manage low blood sugar and how to monitor glucose levels themselves.

All this takes considerable time. A doctor may think they will explain everything at the patient’s next visit. But the patient may not return for months or even a year, sometimes because they fear being advised to start insulin. The delay continues, and this clinical inertia can persist for years.

Meanwhile, patients may develop complications affecting their eyes, heart and kidneys because their blood sugar levels remain above recommended targets.

HPW: Why do some patients continue to have uncontrolled blood sugar levels even after starting insulin?

Dr V Mohan: There can be several reasons. Some patients may become less careful about their diet or sleep because they believe that starting insulin means their diabetes is now under control. Stress can also affect blood sugar levels.

Dosage is another factor. Insulin doses need to be adjusted according to blood sugar monitoring. If patients do not monitor their levels properly, their blood sugar may remain uncontrolled.

Taking insulin is not enough on its own. Patients need appropriate doses, regular monitoring and follow-up care.

HPW: If you could change one thing about India’s healthcare system to improve diabetes care, what would it be?

Dr V Mohan: I would focus on precision diabetes treatment. We now know that not everyone has the same type of diabetes. Some people have type 1, others have type 2, and there are additional forms of the disease.

First, patients need an accurate diagnosis of the type of diabetes they have. Second, the diagnosis must be made early, rather than allowing people to go years without knowing they have the disease.

Third, patients must receive the appropriate treatment, whether oral medicines, insulin or GLP-1 drugs, depending on which treatment is best for them.

Most importantly, there must be regular follow-up. Some people ask why they should attend check-ups when they have no symptoms. This is one of the biggest mistakes they can make. Diabetes is called a silent killer, and the absence of symptoms does not mean that blood sugar levels are under control or that complications are not developing.

Dr V Mohan is an Indian physician specialising in diabetology. He chairs Dr Mohan’s Diabetes Specialities Centre, a hospital chain headquartered in Chennai, designated as a WHO collaboration centre on NCDs. He also chairs the Madras Diabetes Research Foundation (MDRF). He has authored over 1,200 research publications and has been ranked among the world’s top 2% of scientists by Stanford University.

 

Image Credits: WHO/A. Loke, S. Samantaroy/HPW.